Empty sella syndrome presented with arthritis

Abstract

Primary empty sella is defined as the extension of the subarachnoid space toward the intrasellar region, in the absence of pituitary surgery or radiation therapy [1]. Patients with an empty sella may occasionally present symptoms like abnormal endocrine functions, cerebrospinal fluid leakage, and visual field defects [2-4]. Recent reviews outlined the possible relationship between hypothyroidism and autoimmune rheumatological conditions [5,6]. However, there is no evidence of hypopituitarism and rheumatological disorders. We present here an unusual case with primary and partial empty sella presented with symptomatic hypopituitarism and arthritis without any evidence of autoimmune origin.A 57-year-old woman presented with swelling in the knees and pain in the ankles. She had progressive severe fatigue and inability to stand and walk due to pain and fatigue. There was severe effusion and warmth in bilateral knee joints. She also had pain in bilateral ankles without any sign of arthritis. She was hospitalized and the initial laboratory studies showed that the free T3 (0 ng/mg, unmeasurable) and free T4 (0.06 ng/ml) levels were severely decreased. TSH was within normal levels (0.872 IU/ml) but close to the lower normal border. There was mild hypocalcemia (7.9 mg/dl). Morning serum cortisol (3.4 mcg/dl) level was slightly decreased. Prolactin (9.1 ng/ml), FSH (1.17 mIU/ml), LH (0.04 IU/ml), growth hormone (3.3 ng/ml) and ACTH (31.8 pg/ml) levels, blood glucose (66 mg/dl), renal and liver functions, Na (144 mmol/dl) and K (4.5 mmol/dl) were normal. Sedimentation rate was 54 mm/h and C-reactive protein (CRP) was (???) with Latex agglutination test. Brucella agglutination with Rose Bengal test, rheumatoid factor, anti-thyroid peroxidase (anti-TPO), anti-thyroglobulin (anti-Tg) and anti-thyroid microsomal (anti-M) antibodies were negative. There was no sign of infection during the hospitalization and within the 3 months prior to the onset of the symptoms. In addition, the microscopy and culture of throat swab, urine, and stool were negative.Thyroid ultrasonography was normal. Hypophysis magnetic resonance imaging (MRI) revealed a maximum 3 mm thickness of the middle and left lateral part of the hypophysis gland which was consistent with a partial empty sella. Additionally, the infundibular stalk was deviated to the right side. Lesions, which were isointense on T1 and T2 sequences and hypointense following the administration of radiographic contrast media in the right anterior part of the gland were compatible with microadenomas (Fig. 1).The patient was commenced on prednisolon 10 mg, levothyroxine 0.1 mg, diclophenac sodium 150 mg daily. Prednisolon and levotroxine was increased gradually up to the desired dosages. Additionally, cold therapy was used to suppress the pain and the inflammatory findings in the knees and ankles. Arthritis and fatigue improved significantly within the second week of the treatment. Diclophenac sodium was stopped in the second week. There was no sign of any inflammation by clinical examinations ...