55 year female with empty sella

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55year female patient,

Patient was admitted for ACTH stimulation test on May 24 th 2022

15 years ago,she went for routine check up and diagnosed with HTN and started on medication.

9 years ago -she has h/o cough and diagnosed with pulmonary kochs used ATT for 6 months associated with joints pains .

8 years ago- she has h/o increased joint pains - polyarthritis - prescribed with steroids by local doctor and was adviced to taper and stop .But as she stopped using steroids ,the pains increased,so she kept on using steroids continuously for 6-7 years on and off , sometimes daily.

7 years ago ,h/o increased joint pains with facial puffiness and started using thyronorm in view of hypothyroidism

September 2020 came to our hospital with chief complaints of neck pain ,headache and was admitted and treated for uncontrolled hypertension discharged on tab clinidipine 10 MG bd tab Losartan 50 MG Od

one year ago(2021) patient went to USA and stop taking steroids continuously for 15 days . complains of giddiness, vomitings, pain abdomen, headache and was admitted in US found to have sodium 110 ,hypotension ,adrenal insufficiency and findings concerning for pan hypopituitarism ( labs consistent with central hypogonadism , central hypothyroid ,adrenal insufficiency and long-standing usage of chlorthalidone led to hyponatraemia was advised to follow up with endocrinologist and MRI pituitary. and was discharged after sodium correction ,started on cortisol and increased levothyroxine dose to 75MG

Investigations in done at the time of adrenal insufficiency

1.FSH 1.4IU/L(low)

2.LH <0.2IU/L(low)

3.ACTH:18pgm(normal)

4.Serum cortisol 13.9(low)

5.Aldosterone <3.0mcg/dl(low)

6.TSh 1.42(low)

7.Free T4 -0.6(low)

8.IGF 1:<15U(low)

9.Prolactin:20.43(normal)

10.Serum sodium:110

11.urine osmo 195mosm/l

12.urine Na+ 45mosm/l

Suggesting Central hypogonadism,central hypothyroidism ,secondary adrenal insufficiency and hyponatremia secondary to ?chlorthalidone use for hypertension.

Adviced to review with MRI sella to hospital,and was discharged on tab HISONE 5mg -2.5mg-2.5mg and LT4 75mcg OD

Tab cinod 10mg bd

Tab met xl

Tab losartan

But patient returned to India and got MRI brain done

- Menopause attained 10 years age

- k/c/o HTN since 15 years 

-k/c/o hypothyroidism since 7-8 years

Vitals 

Temp- afebrile

Axillary and pubic hair normal

BP-130/90mmhg

PR-89bpm

RR-22cpm

No pallor/icterus/clubbing/ lymphadenopathy

CVS-s1,S2 +

RS- BAE +

P/A - soft ,nontender

CNS- Nad

Patient is continuing on tab HISONE 5mg(6am)-2.5mg(12pm)-2.5mg (4pm) and other hypertension, hypothyroidism medications .

Her only current concern is that if she needs to use the steroids for life long or can she futher taper and stop it.

Did the empty sella really cause her adrenal crisis or was it due to sudden stoppage of steroids?

Ans:plan for ACTH stimulation test ,as she is on very low dose steroid HISONE 5mg-2.5mg-2.5mg since almost an year she may have recovered her HPA axis by now,but if the empty sella is symptomatic she will never recover her HPA axis.

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May 24 ,2020

-Patient is now admitted for ACTH stimulation test as her h/o adrenal insufficiency can be due to empty sella or sudden stoppage of steroids.

Acth stimulation test is planned so as to look if the HPA axis has been recovered as she is on low dose steroids since 1year .

Plan-if HPA axis recovers probably her adrenal crisis was secondary to steroid abuse stoppage,if HPA axis remains suppressed (if serum cortisol levels comes low after ACTH stimulation) - probably her adrenal crisis was due to empty sella but mainly this test is being done to decide if she needs life long supplement of steroids or not.

After skipping the evening dose of steroid and bp monitoring,Acth stimulation test was done on 25/5/2022

Inj.Syntropac 250mcg IV was given at 7 30am,2samples were drawn at 30mins and 60mins(8am and 8 30am).After drawing samples patient was asked to take tab Hisone 5mg as she takes it daily.

ACTH stimulation test result awaited

Patient is not willing for clinical images

Provisional diagnosis:Empty sella syndrome? Chronic steroid abuse admitted for ACTH Stimulation test .k/c/o HTN , Hypothyroidism.

Patient is discharged

Treatment adviced:

1)Tab.Hisone po/Tid 5-2.5-2.5mg

2)Tab.Thyronorm 75mcg 

3)Tab.clinidipine 10mg po/bd

4)Tab.Metaprolol 50mg 

5) Tab.losartan 50mg

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ACTH stimulation test report

8am sample

8 30am sample

Low serum cortisol after ACTH stimulation test suggestive that her HPA axis did not recover and the empty sella is probably responsible for her previous adrenal crisis .She is adviced to continue low dose steroids and follow up .

Questions

Is empty sella the real cause for her adrenal insufficiency?

As the patient had history of TB ,Can it be TB causing pan hypopitutarism?

Can we say pan hypopitutarism is there for sure based on the tests above?

Can it be sudden stoppage of steroid that caused adrenal insufficiency? Based on low sensitivity and specificity of the tests done to prove her pan hypopitutarism.

Approach to adrenal insufficiency

Reference: https://www.thelancet.com/article/S0140-6736(21)00136-7/fulltext