Report: Woman manifests psychosis after pituitary tumor surgery

Case illustrates need for integrated care, researchers said

Patricia Inácio, PhD avatar

by Patricia Inácio, PhD |

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Psychosis may be more common with Cushing’s disease than previously thought, according to a recent U.S. case report about a 47-year-old woman who had surgery to remove a pituitary tumor, but whose signs of psychosis weren’t evident to her hospital team in the months before the procedure.

“This case highlights the value and need for integrated care, since an involved psychiatrist (e.g., as a consultant, part of a collaborative care model, etc…) may well have recognized psychosis prior to surgical treatment,” the researchers wrote in “Cushing Disease Psychosis Identified as Postoperative Psychosis,” which was published in the Journal of the Academy of Consultation-Liaison Psychiatry.

Cushing’s disease is marked by elevated levels of cortisol in the body, called hypercortisolism. It’s caused by a tumor in the pituitary gland that produces and releases abnormally high amounts of the signaling molecule adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands atop the kidneys to overproduce cortisol.

More than two-thirds of people with Cushing’s syndrome — a group of disorders that includes Cushing’s disease — have psychiatric manifestations, including depression, irritability, and anxiety. Other psychiatric manifestations, such as psychosis, are rarer, affecting fewer than 10% of patients who haven’t received any treatment.

Clinicians at the Massachusetts General Hospital, Boston described the case of a woman with Cushing’s disease whose psychosis was immediately evident following surgery to remove a pituitary tumor.

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Onset of psychosis symptoms after surgery

The woman had a history of depression and post-traumatic stress disorder. Following a coronavirus infection more than two years earlier, she became fatigued, developed problems concentrating, had memory decline, and worsening anxiety. In the next two years she developed palpitations, dizziness, and gained weight. She also displayed features of Cushing’s, such as a round face, easy bruising, and a fat pad between the shoulders, called a buffalo hump.

Suspecting hypercortisolism, clinicians ordered standard diagnostic tests to measure cortisol in her saliva and urine along with ACTH levels in her blood, and an overnight dexamethasone suppression test.

Late night salivary cortisol levels were elevated and early morning blood cortisol levels failed to drop after the dexamethasone suppression test, consistent with hypercortisolism. An MRI scan of the pituitary gland confirmed a small benign tumor, called a microadenoma, leading to the diagnosis of Cushing’s disease.

The woman had surgery to remove the microadenoma, with no complications. On the night after the surgery, the psychiatric department was called as she had become suddenly distrustful of her care team and believed she was in the wrong unit. She asked to be discharged against medical advice.

On examination, she appeared guarded and behaved oddly, despite showing no signs of disorientation or lack of attention. The woman said the hospital staff were untrustworthy and her daughters were unsafe.

According to her former partner, she had shown signs of paranoia for several months. She believed she was being recorded at home, and that some of her belongings had been stolen. One night, her daughters awoke with her staring at them and she made multiple suicidal statements in the weeks preceding her admission. The woman was then transferred against her will to the psychiatry department after receiving surgical clearance.

She discontinued the antidepressant bupropion (marketed as Aplenzin, with generics available) and the nervous system stimulants amphetamine/dextroamphetamine (sold as Adderall, among other brand names), and refused antipsychotics.

Her mental state began to improve in the days that followed and after a week she was back to normal, according to her family. Her cortisol levels at her discharge were also normal. The case illustrates the need for primary teams to “maintain a higher index of suspicion for psychosis and consider incorporating screening into pre-surgical evaluation, which may require collaboration with family,” the researchers said.