Abstract


Introduction: 
Secondary adrenal insufficiency typically presents with vague symptoms that can make the diagnosis challenging; moreover, the psychiatric manifestations of the condition, though well described in the literature, are often overlooked in the clinical setting.
Clinical Case: view more

Introduction: 
Secondary adrenal insufficiency typically presents with vague symptoms that can make the diagnosis challenging; moreover, the psychiatric manifestations of the condition, though well described in the literature, are often overlooked in the clinical setting.
Clinical Case:
A 69 year old blind female developed progressive visual hallucinations three months prior to presentation. Her history was significant for partial resection of a suprasellar meningioma at age 38 which was complicated by central hypothyroidism, central diabetes insipidus and permanent optic nerve damage causing complete blindness. At the onset of the symptoms, an EEG was performed at another facility which showed cerebral dysfunction, and she was quetiapine. The hallucinations became increasingly complex, with animals walking in the apartment. At that time, the quetiapine was switched to haloperidol. Later, three men were entering her apartment through a window and one of the men attempted to set her house on fire, so she was brought to our ER.
When she presented to our facility, her HR was 68 and BP 167/80 mmHg. She appeared well-nourished, was alert and fully oriented with normal muscular tone, full power and intact sensation. There were right fronto-temporal scars. She had no light perception to both eyes, horizontal nystagmus and optic nerve pallor bilaterally. Laboratory results showed normal electrolytes, undetectable TSH <0.07 mIU/L, normal free T4 (1.44 ng/dL) and T3 (168 ng/dL). Her fasting glucose varied from 60-72 mg/dL. AM cortisol level was low at 1.6 µg/dl with a minimal rise to 2.14 µg/dl one hour after administration of cosyntropin 250 mcg IM, and plasma ACTH was inappropriately normal at 7.15 pg/mL. CT head showed a remote right frontal craniotomy, right frontotemporal craniectomy with post-aneurysmal clipping, and a partially calcified 3.1 x 1.7 x 3.5cm mass in the suprasellar cistern. Once secondary adrenal insufficiency was identified, she was started on hydrocortisone 10mg in the morning and 5mg in the late afternoon.
Follow Up:
At outpatient follow-up visits, the patient reported improvement of hallucinations, which were now of a far less intrusive tone.
Conclusions:
As the presenting symptoms of chronic adrenal insufficiency are often nonspecific, a high index of suspicion for this condition is paramount, especially in patients with prior pituitary surgery. In this patient, visual hallucinations were the only symptom of secondary adrenal insufficiency. Failure to recognize this condition led to mismanagement with ineffective anti-psychotic regimens before the correct diagnosis was made. This case highlights the importance of periodically re-testing HPA axis function in patients with prior pituitary surgery, and re-examining organic causes of hallucinations when multiple anti-psychotic regimens fail.

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