A CASE OF LYMPHOCYTIC HYPOPHYSITIS WITH HYPOCORTISOLISM AND CRANIAL DIABETES INSIPIDUS

Abstract

INTRODUCTION/BACKGROUND

Lymphocytic Hypophysitis (LH) is an autoimmune pituitary gland disorder that can result in arginine vasopressin deficiency. Low cortisol levels may stimulate antidiuretic hormone (ADH) secretion and promote renal water reabsorption, which can be suppressed by exogenous corticosteroids. We report a case of LH with cranial diabetes insipidus (CDI), initially masked by concurrent hypocortisolism.

CASE

A 26-year-old female presented with a sudden-onset blurring of vision in the left eye, headache and polyuria. The ophthalmologic evaluation revealed optic neuropathy in the left eye, along with bitemporal hemianopia. Pituitary MRI demonstrated a mass measuring 1.1 × 1.2 × 1.6 cm with associated thickening and enhancement of the pituitary infundibulum. The normal posterior pituitary bright spot was also absent.

On admission, her serum sodium was within the normal range, with a serum osmolality of 294 mOsm/kg and a urine osmolality of 793 mOsm/kg. Following the initiation of intravenous methylprednisolone, she developed polyuria. Paired osmolality testing showed a decrease in serum osmolality to 289 mOsm/kg and a drop in urine osmolality to 77 mOsm/kg, consistent with steroid-unmasked CDI. Desmopressin was initiated, resulting in an increase in urine osmolality to 760 mOsm/kg, confirming complete CDI and leading to symptomatic improvement.

Her autoimmune screening and infection markers were negative. She was discharged on oral prednisolone and sublingual desmopressin. At follow-up one month later, her symptoms and vision had significantly improved.

CONCLUSION

Although rare, the onset of polyuria following steroid initiation raises concern for the unmasking of CDI, particularly in patients with concurrent hypocortisolism. Since corticosteroids are the mainstay of medical treatment for LH, recognising this phenomenon is clinically important for timely diagnosis and appropriate management.