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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 187-190

Acute psychoses: An unusual presentation of empty sella syndrome

Department of General Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission04-Oct-2018
Date of Decision13-Nov-2018
Date of Acceptance28-Nov-2018
Date of Web Publication13-Aug-2019

Correspondence Address:
Abhishek Singhai
Department of General Medicine, All India Institute of Medical Sciences, Bhopal - 462 020, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_139_18

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We report a case of a 54-year-old female admitted to our hospital with altered behavior. We found that severe hyponatremia (116 mEq/L) was the cause of the patient's status. In turn, hyponatremia was due to panhypopituitarism. Mild-to-moderate hyponatremia had been previously detected in this patient; however, it was overlooked. The clinical onset of panhypopituitarism is often characterized by mild nonspecific symptoms, especially in the older people, and it is often overlooked. Although hyponatremia is a common electrolyte disorder in the elderly, physicians should not forget that it could be the leading manifestation of panhypopituitarism. Panhypopituitarism may be easily diagnosed; however, clinical suspicion is needed. Due to the high mortality associated with panhypopituitarism, hormone assays should be included in the initial diagnostic workup of hyponatremia.

Keywords: Hyponatremia, hypopituitarism, metabolic encephalopathy

How to cite this article:
Singhai A, Kapur K, Khadanga S, Paramanandam A. Acute psychoses: An unusual presentation of empty sella syndrome. CHRISMED J Health Res 2019;6:187-90

How to cite this URL:
Singhai A, Kapur K, Khadanga S, Paramanandam A. Acute psychoses: An unusual presentation of empty sella syndrome. CHRISMED J Health Res [serial online] 2019 [cited 2020 Aug 12];6:187-90. Available from: http://www.cjhr.org/text.asp?2019/6/3/187/264374

  Introduction Top

Panhypopituitarism is a condition of loss of function of anterior pituitary gland characterized by the inadequate or absent production of anterior pituitary hormones. It is a rare condition that can present at any age and is caused by pathology of the hypothalamic-pituitary axis or one of the many gene mutations. The symptoms and signs of panhypopituitarism may occur over several years and can be nonspecific or related to the effects of underlying disease or due to hormone deficiencies. Panhypopituitarism is a condition that is often misdiagnosed. Panhypopituitarism is an underinvestigated endocrine disorder in the elderly since its clinical features are nonspecific and more commonly present to aging itself and related comorbidities.[1],[2] Although diagnosis of panhypopituitarism is easy if clinical suspicion is high.[1],[2],[3]

Empty sella syndrome (ESS) is where the pituitary gland shrinks or becomes flattened, filling the sella turcica with cerebrospinal fluid on imaging instead of the normal pituitary. ESS can be found in the diagnostic workup of pituitary disorders, or as an incidental finding when imaging the brain.

Hyponatremia is a common electrolyte disorder, especially in the elderly;[4],[5],[6],[7] however, it is also a laboratory sign of panhypopituitarism.[1],[2] Hyponatremia, as the presenting manifestation of ESS, is rare. Here, we describe a case of middle-aged female who presented with acute psychoses due to hyponatremia, and who, later on, found to have panhypopituitarism with empty sella.

  Case Report Top

A 54-year-old female presented with dullness, irrelevant talking, and inability to recognize her relatives for 5 days. She had abnormal behavior, with decreased sleep. There was no history of fever, headache, head trauma, or violent behavior. For the above complaints, she was admitted to the psychiatry department. She had similar episode 1 year back for which she took symptomatic treatment and improved. On examination, the patient was dull, drowsy, and disoriented to time, place, and person. She had madarosis, hoarseness of voice, and diffusely sparse hairs over the body (axillary and pubic hair). Neck rigidity was absent and both planters were flexor. Pulse was 60/min, and blood pressure was on a lower side of around 90/60 mmHg on repeated measurements, and other systemic examination findings were normal.

Her investigations showed hemoglobin 8.6 g/dl (11–15), white blood cell count 3530/mm 3 (4000–11,000), mean corpuscular volume 88.2 fl (80–100), platelet count 145,000/mm 3 (150,000–450,000), random blood glucose values were always below 100 mg/dl on repeated measurements, serum creatinine 0.71 mg/dl (0.5–0.9), blood urea 17 mg/dl (20–40), serum sodium 116 mEq/L (136–145), serum potassium 3.58 mEq/L (3.5–5.1), serum chloride 87 mEq/L (98–107), serum bilirubin 0.63 mg/dl (0.3–1.2), alanine aminotransferase 52 IU/L (0–35), aspartate aminotransferase 99 IU/L (0–35), alkaline phosphatase 83 IU/L (30–120), erythrocyte sedimentation rate 10 mm (1–10), and serum albumin 4.10 (3.5–5.5). Then, the patient was referred to physician in view of hyponatremia. The patient was treated with 3% saline.

Further workup for hormone assays and radiological investigation was planned and reports were as follows: T3 0.22 ng/ml (0.6–1.81), T4 0.7 mcg/dl (4.5–10.9), free T4 0.11 (0.89–1.77), thyroid-stimulating hormone 2.85 mcg U/ml (0.35–5.5), random serum cortisol 1.45 mcg/dl (4.30–22.40), adrenocorticotropic hormone 14.50 pg/ml (<46.00), and follicle-stimulating hormone 12.41 mU/ml (15.9–54). These investigations were suggestive of panhypopituitarism. [Table 1] shows the symptoms and clinical signs that favor hypopituitarism. No significant brain parenchymal abnormality was seen on noncontrast computed tomography head. After this, magnetic resonance imaging brain with contrast was planned, which showed empty sella with a significantly reduced size of the anterior pituitary gland (approximately 1.5-mm thickness) with no adenoma [Figure 1]. The posterior pituitary bright spot is seen normal, the pituitary stalk is seen normal in position, and a tiny focus of microhemorrhage is noted involving right paraventricular region. Following this, the patient was treated with 50 mcg of thyroxine, prednisolone 5 mg in the morning, and 2.5 mg in the evening with fludrocortisone 0.1 mg once a day. Gradually, the patient's general condition improved with the above treatment, serum sodium was corrected, and the patient was discharged after 8 days of hospitalization in stable condition.
Table 1: Anterior pituitary hormones and presentation of their deficiency

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Figure 1: Magnetic resonance imaging brain showing empty sella with significantly reduced size of anterior pituitary gland (approximately 1.5-mm thickness) with no adenoma

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  Discussion Top

This case report highlights the importance of extensive workup in a case of hyponatremia. Panhypopituitarism is a relatively rare disorder, with its incidence and prevalence being 4.2 per 100,000 per year and 45.5 per 100,000, respectively.[1] Panhypopituitarism usually develops gradually and insidiously; symptomatology is unspecific so that diagnosis is often delayed.[2],[3]

There are two types of ESS which are as follows: primary and secondary. Primary ESS happens when a small anatomical defect above the pituitary gland increases pressure in the sella turcica and causes the gland to flatten out along the interior walls of the sella turcica cavity. Primary ESS is associated with obesity and an increase in intracranial pressure in women.[8] In most cases, especially in people with primary ESS, there are no symptoms and it does not affect life expectancy. Some researchers have estimated that less than 1% of affected people ever develop symptoms of the condition.

Secondary ESS is the result of the pituitary gland regressing within the cavity after an injury, surgery, or radiation therapy. Individuals with secondary ESS due to the destruction of the pituitary gland have symptoms that reflect the loss of pituitary functions such as intolerance to stress and infection.

Stable patients who are diagnosed with panhypopituitarism have a favorable prognosis with replacement hormone therapy; however, patients with acute decompensation are in critical condition and may have a high mortality rate. Four retrospective studies from the United Kingdom and Sweden showed that mortality is increased by 1.3–2.2 fold in patients with panhypopituitarism, compared with age- and sex-matched cohorts.[9] Morbidity is variable and may depend on hormone deficiency, underlying disease, or inadequate long-term replacement therapy.

Recent studies have shown that people with a previous traumatic brain injury, spontaneous subarachnoid hemorrhage (a type of stroke), or radiation therapy involving the head have a higher risk of panhypopituitarism.[10] After traumatic brain injury, as much as a quarter have persistent pituitary hormone deficiencies.[11] Many of these people may have subtle or nonspecific symptoms that are not linked to pituitary problems but are attributed to their previous condition. Hence, it is possible that many cases of panhypopituitarism remain undiagnosed, and the annual incidence would rise to 31 per 100,000 annually if the people are from these risk groups were to be tested.[4]

The term hyponatremia is defined as a serum sodium concentration <136 mEq/L. It is a common electrolyte abnormality in the general population and also in hospitalized patients.[6],[12] Patients who present with mild-to-moderate forms of hyponatremia (126-135 mEq/L) may be asymptomatic and are often overlooked. A careful history, including pharmacological history and physical examination, often provides useful clues to the underlying cause.

Thiazide diuretics and the syndrome of inappropriate antidiuretic hormone secretion are the most common causes of hyponatremia encountered in clinical practice.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Hyponatremia could be an early sign of severe medical conditions such as panhypopituitarism.[3] The onset of panhypopituitarism may be insidious and sometimes with mild nonspecific symptoms. Symptoms such as loss of energy, fatigue, and decreased libido are common in the elderly, thus physicians often fail in misdiagnosis and consider hyponatremia as a normal consequence of aging.[1],[3] [Table 2] shows the new class of drugs available for the treatment of hyponatremia.
Table 2: New class of drugs for hyponatremia

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  Conclusion Top

ESS is a rare disease, and most of the time it left undiagnosed, and patients with panhypopituitarism are at high mortality risk; hence, hormone assays should be included in the initial diagnostic workup of hyponatremia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Higham CE, Johannsson G, Shalet SM. Hypopituitarism. Lancet 2016;388:2403-15.  Back to cited text no. 1
Curtò L, Trimarchi F. Hypopituitarism in the elderly: A narrative review on clinical management of hypothalamic-pituitary-gonadal, hypothalamic-pituitary-thyroid and hypothalamic-pituitary-adrenal axes dysfunction. J Endocrinol Invest 2016;39:1115-24.  Back to cited text no. 2
Wakil A, Ng JM, Atkin SL. Investigating hyponatraemia. BMJ 2011;342:d1118.  Back to cited text no. 3
Liamis G, Rodenburg EM, Hofman A, Zietse R, Stricker BH, Hoorn EJ, et al. Electrolyte disorders in community subjects: Prevalence and risk factors. Am J Med 2013;126:256-63.  Back to cited text no. 4
Drake-Holland AJ, Noble MI. The hyponatremia epidemic: A frontier too far? Front Cardiovasc Med 2016;3:35.  Back to cited text no. 5
Giordano M, Ciarambino T, Castellino P, Malatino L, Di Somma S, Biolo G, et al. Diseases associated with electrolyte imbalance in the ED: Age-related differences. Am J Emerg Med 2016;34:1923-6.  Back to cited text no. 6
Catalano A, Basile G, Lasco A. Hypocalcemia: A sometimes overlooked cause of heart failure in the elderly. Aging Clin Exp Res 2012;24:400-3.  Back to cited text no. 7
Wael F. Review of empty sella syndrome and its surgical management. Alex J Med 2011;47:139-47.  Back to cited text no. 8
Clayton RN. Mortality, cardiovascular events and risk factors in hypopituitarism. Growth Horm IGF Res 1998;8 Suppl A: 69-76.  Back to cited text no. 9
Schneider HJ, Kreitschmann-Andermahr I, Ghigo E, Stalla GK, Agha A. Hypothalamopituitary dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage: A systematic review. JAMA 2007;298:1429-38.  Back to cited text no. 10
Behan LA, Phillips J, Thompson CJ, Agha A. Neuroendocrine disorders after traumatic brain injury. J Neurol Neurosurg Psychiatry 2008;79:753-9.  Back to cited text no. 11
Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE. Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med 2010;170:294-302.  Back to cited text no. 12


  [Figure 1]

  [Table 1], [Table 2]


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