ACTH Secreting Pituitary Microadenoma Presenting with Acute Psychosis, Delirium and Paroxysmal Sympathetic Hyperactivity

ACTH secreting pituitary adenomas are known to be associated with behavioral changes but acute presentation including psychosis and delirium are less common. We report the case of a 42-year-old lady with a known medical history of hypertension and diabetes mellitus, presenting with acute onset behavioral changes suggestive of psychosis. Further evaluation revealed an ACTH dependent Cushing’s disease with a pituitary microadenoma. The patient was admitted for endoscopic resection of the adenoma. During the peri-operative period, she experienced worsening of psychosis along with delirium. She also developed episodes of unresponsiveness, posturing, severe diaphoresis and dyspnea accompanied by tachycardia and hypertension which were managed with Midazolam and Levetiracetam. A seizure work-up and CT brain were unremarkable. At follow-up, she showed full resolution of symptoms with good blood pressure and glycemic control. ACTH secreting pituitary microadenoma presenting with acute psychosis, delirium and paroxysmal sympathetic hyperactivity. Keywords: Cushing’s disease, neuropsychiatric, dysautonomia.