{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T08:40:54Z","timestamp":1793349654634,"version":"4.5.0"},"reference-count":18,"publisher":"Bioscientifica","content-domain":{"domain":["edm.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2013,8,1]]},"abstract":"Summary<\/jats:title>\n A 46-year-old woman presented multiple times in a 4-month period with hypotension, sepsis, hypoglycaemia and psychosis. A low random cortisol in combination with her presenting complaint made adrenal insufficiency the likely diagnosis. Fluid resuscitation and i.v. steroid therapy led to clinical improvement; however, a short synacthen test (SST) demonstrated an apparently satisfactory cortisol response. The test was repeated on a later admission and revealed a peak cortisol level of 25\u200anmol\/l (>550\u200anmol\/l). Concurrent treatment with i.v. hydrocortisone had led to a false-negative SST. ACTH was <5\u200ang\/l (>10\u200ang\/l), indicating secondary adrenal failure. We discuss the challenges surrounding the diagnosis of adrenal insufficiency and hypopituitarism, the rare complication of psychosis and a presumptive diagnosis of autoimmune lymphocytic hypophysitis (ALH).<\/jats:p>\n \n Learning points<\/jats:title>\n \n \n \n Adrenocortical insufficiency must be considered in the shocked, hypovolaemic and hypoglycaemic patient with electrolyte imbalance. Rapid treatment with fluid resuscitation and i.v. corticosteroids is vital.<\/jats:p>\n <\/jats:list-item>\n \n Polymorphic presentations to multiple specialities are common. Generalised myalgia, abdominal pain and delirium are well recognised, psychosis is rare.<\/jats:p>\n <\/jats:list-item>\n \n A random cortisol can be taken with baseline bloods. Once the patient is stable, meticulous dynamic testing must follow to confirm the clinical diagnosis.<\/jats:p>\n <\/jats:list-item>\n \n The chronic disease progression of ALH is hypothesised to be expansion then atrophy of the pituitary gland resulting in empty sella turcica and hypopituitarism.<\/jats:p>\n <\/jats:list-item>\n \n \n If hypopituitarism is suspected, an ACTH deficiency should be treated prior to commencing thyroxine (T\n 4<\/jats:sub>\n ) therapy as unopposed T\n 4<\/jats:sub>\n may worsen features of cortisol deficiency.\n <\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1530\/edm-13-0007","type":"journal-article","created":{"date-parts":[[2013,8,30]],"date-time":"2013-08-30T06:46:19Z","timestamp":1377845179000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-2","source":"Crossref","is-referenced-by-count":6,"title":["A rare case of hypopituitarism with psychosis"],"prefix":"10.1530","volume":"2013","author":[{"given":"M","family":"Nwokolo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J","family":"Fletcher","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","reference":[{"key":"ref11","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1007\/s11102-006-0408-5","article-title":"Isolated corticotrophin deficiency","volume":"9","year":"2006","journal-title":"Pituitary"},{"key":"ref71","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1258\/acb.2009.009209","article-title":"National UK audit of the short synacthen test","volume":"47","year":"2010","journal-title":"Annals of Clinical Biochemistry"},{"key":"ref151","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/j.1365-2265.2009.03765.x","article-title":"How reliably can autoimmune hypophysitis be diagnosed without pituitary biopsy","volume":"73","year":"2010","journal-title":"Clinical Endocrinology"},{"key":"ref21","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1530\/eje.0.1490363","article-title":"Lymphocytic hypophysitis: a rare or underestimated disease?","volume":"149","year":"2003","journal-title":"European Journal of Endocrinology"},{"key":"ref31","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1210\/er.2004-0011","article-title":"Autoimmune hypophysitis","volume":"26","year":"2005","journal-title":"Endocrine Reviews"},{"key":"ref111","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1530\/eje.0.1490363","article-title":"Lymphocytic hypophysitis: a rare or underestimated disease?","volume":"149","year":"2003","journal-title":"European Journal of Endocrinology"},{"key":"ref161","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1258\/acb.2009.009209","article-title":"National UK audit of the short synacthen test","volume":"47","year":"2010","journal-title":"Annals of Clinical Biochemistry"},{"key":"ref01","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1046\/j.1365-2265.1998.00611.x","article-title":"Secondary adrenal insufficiency associated with autoimmune disorders: a report of twenty-five cases","volume":"49","year":"1998","journal-title":"Clinical Endocrinology"},{"key":"ref81","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1176\/jnp.2006.18.4.450","article-title":"The neuropsychiatric profile of Addison's disease: revisiting a forgotten phenomenon","volume":"18","year":"2006","journal-title":"Journal of Neuropsychiatry and Clinical Neurosciences"},{"key":"ref51","doi-asserted-by":"crossref","first-page":"4190","DOI":"10.1210\/en.2011-1004","article-title":"From pituitary expansion to empty sella: disease progression in a mouse model of autoimmune hypophysitis","volume":"152","year":"2011","journal-title":"Endocrinology"},{"key":"ref101","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1007\/s11102-006-0408-5","article-title":"Isolated corticotrophin deficiency","volume":"9","year":"2006","journal-title":"Pituitary"},{"key":"ref41","first-page":"404","article-title":"Isolated secondary adrenal insufficiency \u2013 an underestimated consequence of asymptomatic autoimmune hypophysitis","volume":"74","year":"2011","journal-title":"Clinical Endocrinology"},{"key":"ref171","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1176\/jnp.2006.18.4.450","article-title":"The neuropsychiatric profile of Addison's disease: revisiting a forgotten phenomenon","volume":"18","year":"2006","journal-title":"Journal of Neuropsychiatry and Clinical Neurosciences"},{"key":"ref121","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1210\/er.2004-0011","article-title":"Autoimmune hypophysitis","volume":"26","year":"2005","journal-title":"Endocrine Reviews"},{"key":"ref131","first-page":"404","article-title":"Isolated secondary adrenal insufficiency \u2013 an underestimated consequence of asymptomatic autoimmune hypophysitis","volume":"74","year":"2011","journal-title":"Clinical Endocrinology"},{"key":"ref91","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1046\/j.1365-2265.1998.00611.x","article-title":"Secondary adrenal insufficiency associated with autoimmune disorders: a report of twenty-five cases","volume":"49","year":"1998","journal-title":"Clinical Endocrinology"},{"key":"ref141","doi-asserted-by":"crossref","first-page":"4190","DOI":"10.1210\/en.2011-1004","article-title":"From pituitary expansion to empty sella: disease progression in a mouse model of autoimmune hypophysitis","volume":"152","year":"2011","journal-title":"Endocrinology"},{"key":"ref61","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/j.1365-2265.2009.03765.x","article-title":"How reliably can autoimmune hypophysitis be diagnosed without pituitary biopsy","volume":"73","year":"2010","journal-title":"Clinical Endocrinology"}],"container-title":["Endocrinology, Diabetes & Metabolism Case 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