Recovery from osmotic demyelination syndrome associated with pituitary macroadenoma

45 years old female known case of hypothyroid admitted to local nursing home with pain abdomen, vomiting and generalized weakness. She received intravenous fluids and antibiotics in a nearby hospital. She experienced hyponatremia, which hypertonic saline from 104 to 128 meq/l quickly treated. Modified Rankin scale score was >3. MRI brain done showed pituitary macroadenoma. She was transferred to our hospital after 5 days because of altered sensorium and bradykinesia of all 4 limbs with high grade fever and unexpected MRI finding. Treatment was started initially in line of meningitis but CSF study was negative. She was intubated for airway protection later tracheostomy was done. MRI brain repeated after 15 days showed pontine and extrapontine demyelination. Serum cortisol was low due to secondary adrenal insufficiency so started on steroid therapy. She improved gradually regained consciousness, started obeying commands, decannulated and discharged with Rankin score <1 after 2 months of steroid and thyronorm supplements and extensive supportive therapy.