INTRODUCTION

The pituitary gland is located in the sella turcica and is attached to the base of the brain by the pituitary stalk which passes through the diaphragma sellae, a thick layer of the dural membrane. Some- times the diaphragma sellae is incomplete and the subarachnoid space extends into the pituitary fossa flattening the pituitary gland which forms a thin layer at the sellar base. Busch (1951) has called this the 'empty sella'[1]. When the pituitary gland shrinks or becomes flattened it cannot be seen on the MRI scan making it look like an empty sella. This is called as empty sella syndrome. It is of two types, primary and secondary. Primary empty sella occurs when a hole in diaphragmatic sella covering the pituitary allows fluid in, which presses on the pituitary. Secondary empty sella syndrome occurs when the pituitary gland is damaged by a tumor, surgery or radiation therapy [2]. Herein we discuss a case of empty sella syndrome of unclear etiology and were determined later on hospital admission supported by the radiographic imaging. This syndrome is relatively new and not much reported on a routine basis, hence radiographical imaging helps in its management.

CASE HISTORY

48 year old female patient presented to our hospital with complaints of fever, severe generalised weakness, and decreased oral intake for the past 3 days. She was admitted to our hospital in the view of COVID-19 with an RT-PCR test done from a nasopharyngeal swab. While awaiting the results for COVID-19, she was cared for in the COVID ward where she had routine tests done including Gene pert MTB, CSF analysis. She first had a hypoglycaemic episode a day after her admission [when checking her blood sugar level was low was given 5% dextrose and BSL returned to normal. And the next day again the same happened. Upon further enquiry she was diagnosed with viral myocarditis in 2018. She had initial symptoms of water retention, shortness of breath, weakness for 2 months. 2D-Echo initially had an ejection fraction of 20%. She had a unique presentation of low sodium of 135mmol/L for which she was not treated given water. She was treated for viral myocarditis and was discharged later on with maintenance drugs her LVEF improved [35%]. Since her discharge, a continuous low sodium level of 128mEq/L was noted on routine labs. She was advised to take a high salt diet which showed no correction in her subsequent sodium levels. She was advised to take salt capsules later on and was told to undergo tests checking her serum cortisol level in 2019, which was <0.4 ug/dL, Hydrocortisone started. Presently upon her positive RT-PCR status, she was managed in COVID wards for 10 days. Her CT chest showed CORADS 4 CTSS 5/25. On the 11th day, she was shifted to the ICU because of acute delusions and dehydration. Her serum cortisol was low so serum ACTH was done which was <1.5 pg/mL). MRI brain done suggestive of mild generalised cerebral atrophy with empty sella. MRI angiography revealed mild narrowing of distal petrous and cavernous segment of bilateral ICA and a 4 x 5 mm in size focal out pouching suggestive of aneurysm seen in the supraclinoid segment of right ICA. Serum TSH T3 T4, IGF-1, PTH, Prolactin was ordered subsequently with serum microsomal TPO antibody and serum thyroglobulin antibody and full antibody panel of autoimmune disorders. All other antibodies were within normal limits. The patient eventually improved upon starting her on steroids and was ultimately shifted to the medicine wards. She was counselled on her medical condition and medication for the same.