Endocrine Abstracts

Introduction: Psychiatric disturbance is a recognised complication of glucocorticoid therapy. Patients on a daily dose of 40 mg of prednisolone or its equivalent are at risk of developing steroid psychosis. Psychotic reactions with replacement doses of glucocorticoid are uncommon. We describe a patient with newly diagnosed hypopituitarism who developed severe steroid induced psychosis with low dose hydrocortisone.

Case report: A 72-year-old lady presented with chronic headaches, anorexia, and nausea and weight loss. Investigations showed severe hyponatraemia (serum sodium 119 mmol/l) and a Short Synacthen test confirmed adrenal insufficiency (base line cortisol 12 mmol/l, 30 min 171 nmol/l, 60 min 262 nmol/l). Biochemical evaluation also demonstrated thyrotroph and gonadotroph failure. Pituitary MRI scan showed a large cystic pituitary mass. The patient was commenced on intravenous hydrocortisone (50 mg QDS) in view of anorexia, nausea and hypotension. She developed severe psychosis with vivid visual and auditory hallucinations after 5 doses of intravenous hydrocortisone. The hallucinations persisted despite reducing the dose of hydrocortisone to 5 mg/day. Hydrocortisone was therefore discontinued for 48 h. Treatment with Haloperidol (2 mg/day) resulted in complete resolution of hallucinations. Hydrocortisone was re-introduced at 5 mg/day and gradually increased to 20 mg/day in divided doses without any recurrence of symptoms.

Discussion: Steroid induced psychosis in the context of hypopituitarism is extremely rare and has only been described in a patient with Sheehan’s syndrome treated with oral Prednisolone. We are unaware of any other reports of this occurring in hypopituitarism treated with replacement dose Hydrocortisone. A putative mechanism of this phenomenon is that long standing hypoadrenalism leads to neurological adaptation and that steroid therapy may lead to rapid central nervous system resensitization which manifests as psychosis. This case highlights the fact that patients with longstanding hypoadrenalism are at risk of this complication and need to monitor closely when steroid therapy is introduced.