Arachnoid Cyst Manifesting as Panhypopituitarism in the Setting of Septic Shock

Case Report

Austin J Clin Case Rep. 2014;1(5): 1021.

Arachnoid Cyst Manifesting as Panhypopituitarism in the Setting of Septic Shock

Kariuki N1*, Rai AK1 and Shetty V2

1Department of Internal Medicine, Maimonides Medical Center, USA

2Division of Cardiology, Maimonides Medical Center, USA

*Corresponding author: Kariuki N, Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, New York 11219, USA

Received: May 31, 2014; Accepted: June 25, 2014; Published: June 27, 2014


Pituitary cystic sellar masses typically present with symptoms of headache and visual impairment Endocrinologic manifestations are less common. We describe a case of a sixty-two year-old female who presented with altered mental status. She initially appeared to be in septic shock but was also found to have panhypopituitarism secondary to an arachnoid cyst. This case highlights the diagnostic workup of panhypopituitarism in the emergent setting, and demonstrates how this diagnosis maybe masked by other clinical entities.

Keywords: Panhypopituitarism; Sellar masses; Arachnoid cyst; Adrenal stimulation testing; Critical illness related corticosteroid insufficiency


TSH: Thyroid Stimulating Hormone; FSH: Follicle Stimulating Hormone; IGF-1: Insulinlike Growth Factor; MSSA: Methicillin-sensitive Staphylococcus Aureus; CIRCI: Critical-illnessrelated-corticosteroid Insufficiency

Case Presentation

A 62 year-old female with no known past medical history presented to our emergency room with altered mental status. Her neighbors had not seen her for two days and therefore notified EMS. She was found unresponsive at home, covered in feces and urine. Further history could not be obtained due to her mental state. On physical examination, she was hypothermic (oral temperature 84F), hypotensive (BP 77/59 mmHg), in a stupor and unable to follow commands. She opened her eyes spontaneously but had bilateralvisual impairment with absent pupillary light reflexes (both direct and consensual). Deep tendon reflexes were normal with a normal relaxation phase and Babinski sign was negative. In addition, she had stage three sacral decubiti and lower extremity partial thickness wounds. The rest of the physical examination was unremarkable, including lungs, heart and abdomen.

She was intubated for airway protection. Fluid resuscitation was unsuccessful and she was started on pressors. She received Dextrose 50% IV push for hypoglycemia (finger stick glucose 33 mg/dL). EKG showed sinus bradycardia with Osborne waves (J waves). Preliminary blood work was significant for leukopenia (total white blood cell count 2.6 K/UL with 86% neutrophils) and normocytic anemia (hemoglobin 10.3g/dL). CT Head showed a cystic lesion in the sellar region in the absence of midline and hydrocephalus. Hypopituitarism was suspected at this point and a serum cortisol was drawn. She was subsequently started on IV Levothyroxine 125 mcg q24h and IV Hydrocortisone 100mg q8h.

Results of further workup are listed in Table 1. Her low-normal serum cortisol level despite the presence of critical illness was suggestive of adrenal insufficiency. FSH was inappropriately low for the post-menopausal phase, indicating secondary hypogonadism. Low-normal TSH with low free T3 and T4 was consistent with secondary hypothyroidism. Serum IGF-1 was also low. Collectively, this indicated a central etiology for her hormone deficiencies. There was no evidence of hyperprolactinemia. Overall, these findings were consistent with panhypopituitarism, which correlated clinically with the abnormal visual examination and suprasellar mass. Myxedema coma was among the differential diagnoses, although it was not apparent given the absence of hyponatremia with normal deep tendon reflexes and normal serum creatine phosphokinase levels.

She was also started on broad-spectrum antibiotics for presumed septic shock. Preliminary blood cultures grew Methicillinsensitive Staphylococcus aureus (MSSA) and she was switched to Trimethoprime-Sulfamethoxazole (TMP-SMX) based on culture sensitivity. Chest X-ray was negative for focal consolidation; transthoracic echocardiogram was negative for valvular vegetations. The bacteremia was attributed to a stage three sacral decubitus ulcer and partial thickness skin tears on her feet.

A follow-up brain MRI confirmed symmetric enlargement and expansion of the sella with erosion of the dorsum sellae filled with a 3.3 x 3.1 x 3.4 cm non-enhancing cystic mass of cerebrospinal fluid signal intensity extending into the suprasellar region and displacing the optic chiasm (Figures 1&2). The patient declined surgical intervention.

Citation: Kariuki N, Rai AK and Shetty V. Arachnoid Cyst Manifesting as Panhypopituitarism in the Setting of Septic Shock. Austin J Clin Case Rep. 2014;1(5): 1021. ISSN 2381-912X