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We reported a case of a 68-year-old man who presented with recurrent fever and multiorgan dysfunction. His significantly elevated procalcitonin and C-reactive protein levels indicated recurrent sepsis. However, no focus of infection and no pathogens were identified through a variety of examinations and tests. Although the increase of creatine kinase was less than five times the upper limit of normal value, the diagnosis of rhabdomyolysis secondary to adrenal insufficiency resulting from primary empty sella syndrome was finally made, as supported by serum myoglobin elevation, serum cortisol, and adrenocorticotropic hormone deficiency, bilateral adrenal atrophy on computed tomography, and empty sella on magnetic resonance imaging. After the glucocorticoid replacement treatment, the patient's myoglobin gradually returned to normal range, and his condition continued to improve. Rhabdomyolysis resulting from a rare cause may be misdiagnosed as sepsis in patients who present with increased procalcitonin levels.

The sella turcica is the normal neuroanatomical location of the pituitary gland. Empty sella syndrome (ESS) is a rare condition in which the sella turcica is partially or completely filled with cerebrospinal fluid. It is a radiological diagnosis that is often made incidentally following imaging for another reason (eg, to exclude intracranial hemorrhage following head injury) or as part of the work-up when investigating a patient's neurological symptoms. ESS can be classified as primary or secondary, depending on the identification of underlying etiologies. We report the highly unusual case of a 74-year-old patient who presented with progressive neurological disturbance many years after receiving intrathecal chemotherapy. Clinical assessment (including cross-sectional imaging) led to a diagnosis of secondary ESS.

Hypothyroidism is a common pathological condition of thyroid hormone deficiency that varies widely in relation to both the acuity with which the deficiency develops and the clinical manifestations of the disease. While hypothyroidism is commonly mild or even subclinical, one rare complication of hypothyroidism that can cause multiorgan dysfunction is myxedema coma. Myxedema coma is precipitated by an acute stressor such as infection, surgery, or trauma, which disrupts the otherwise compensatory mechanisms present in severe hypothyroidism. Swift diagnosis and treatment of the condition is vital to improving patient outcomes as mortality from myxedema coma ranges from 40 to 60%. The mainstay of treatment includes IV levothyroxine (LT4) with or without the use of liothyronine (LT3). Here we present a case of a patient who presented with presyncope in the setting of generalized fatigue, poor appetite, anhedonia, and slowed speech and movement. Full workup revealed hypotension, hyponatremia, hypoglycemia, respiratory acidosis, undetectable cortisol, free T4, total T4 and an inappropriately normal TSH level. A diagnosis of myxedema coma and adrenal crisis due to pituitary dysfunction was made. A combination of 300 mcg IV LT4 and 5 mcg IV LT3 every 8 hours was used with successful resolution of the patient's symptoms. The patient is currently well maintained on a combination of oral LT4 and hydrocortisone replacement with no further endocrinological complications. This case underscores the need for physicians to maintain a high index of suspicion for secondary adrenal insufficiency and central hypothyroidism in patients with compatible symptoms or risk factors. Furthermore, it also highlights the successful treatment of adrenal crisis and myxedema coma with severe cardiogenic shock with a combination of hydrocortisone, levothyroxine, and liothyronine therapy.

Pembrolizumab, an anti-programmed death-1 specific monoclonal antibody is a second-line treatment for metastatic urothelial carcinoma. Physicians should be aware of adverse immune-related events associated with the use of immune checkpoint inhibitors, particularly adrenocortical insufficiency, which poses a risk of death.We report a case of secondary adrenocortical insufficiency due to isolated adrenocorticotropic hormone deficiency with empty sella syndrome after pembrolizumab treatment in a patient with metastatic renal pelvic cancer. Fortunately, a therapeutic effect was observed 4 months after discontinuation of pembrolizumab, and a durable antitumor response has persisted for 5 months.

Empty sella is a pituitary disorder characterized by the herniation of the subarachnoid space within the sella turcica. This is often associated with a variable degree of flattening of the pituitary gland. Empty sella has to be distinguished in primary and secondary forms. Primary empty sella (PES) excludes any history of previous pituitary pathologies such as previous surgical, pharmacologic, or radiotherapy treatment of the sellar region. PES is considered an idiopathic disease and may be associated with idiopathic intracranial hypertension. Secondary empty sella, however, may occur after the treatment of pituitary tumors through neurosurgery or drugs or radiotherapy, after spontaneous necrosis (ischemia or hemorrhage) of chiefly adenomas, after pituitary infectious processes, pituitary autoimmune diseases, or brain trauma. Empty sella, in the majority of cases, is only a neuroradiological finding, without any clinical implication. However, empty sella syndrome is defined in the presence of pituitary hormonal dysfunction (more frequently hypopituitarism) and/or neurological symptoms due to the possible coexisting of idiopathic intracranial hypertension. Empty sella syndrome represents a peculiar clinical entity, characterized by heterogeneity both in clinical manifestations and in hormonal alterations, sometimes reaching severe extremes. For a proper diagnosis, management, and follow-up of empty sella syndrome, a multidisciplinary approach with the integration of endocrine, neurological, and ophthalmological experts is strongly advocated., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Empty sella is an anatomic finding that is usually asymptomatic. However, when patients with empty sella finding present with visual deficits, surgical treatment may be necessary. The main goal of surgery is to elevate sellar content through a transsphenoidal approach. The aim of this study was to demonstrate a new technique for precise reconstruction of the sellar floor using a heterologous bone block to restore the anatomic elements of the sella turcica., Methods: Three patients with primary empty sella who presented with visual field defects were prospectively included. Surgery was performed through a microsurgical transsphenoidal approach and involved elevating the sellar content by using a tricortical heterologous bone graft, the dimensions of which were obtained considering the exact dimensions of each patient's sella turcica. The graft was premodeled outside the surgical bed and carefully introduced into the sella turcica to achieve the required elevation (chiasmapexy)., Results: Vision of all 3 patients improved, and the improvement persisted throughout the follow-up period. 2 patients, this improvement was noted immediately after surgery, and in the third patient, this change in vision occurred 1 week later. Long-term imaging studies showed the persistence of the bone graft in the sella turcica and the exact elevation of the sellar content at the end of the follow-up period. There were no complications in the present series., Conclusions: The technique presented here is simple and reproducible and allows an almost exact and persistent elevation of the sellar content., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Visual field deterioration caused by secondary empty sella after cabergoline therapy for prolactinoma is a rare event. Chiasmapexy is performed to treat empty sella syndrome. Although various materials have been used for the elevation of the optic chasm, the most appropriate material remains to be established. Here, we describe the efficiency of chiasmapexy for empty sella syndrome following dopamine agonist treatment and the utility of septal cartilage and sphenoidal sinus bone as materials for chiasmapexy., Case Description: A 35-year-old male with a history of cabergoline therapy for prolactinoma presented with visual deterioration. His magnetic resonance imaging revealed optic chiasm herniation into the empty sella. Endoscopic endonasal transsphenoidal chiasmapexy was performed using septal cartilage and sphenoidal sinus bone as materials for elevating the chiasm. Visual function improved immediately after operation., Conclusions: Chiasmapexy is an effective surgical method for treating visual deterioration caused by empty sella after cabergoline treatment. Endoscopic endonasal chiasmapexy with septal cartilage and sphenoidal sinus bone is a considerable option because it is minimally invasive and involves decreased risk of infection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Prolactinomas are typically treated nonsurgically with a dopamine agonist. Once the tumor shrinks, adjacent eloquent structures, such as the optic apparatus, can become skeletonized and herniate into the dilated parasellar space., Case Description: A 48-year-old man with a prolactin-secreting macroadenoma treated with cabergoline presented with progressive bitemporal hemianopsia. Magnetic resonance imaging showed no recurrence of disease and a stretched optic chiasm herniating into an empty sella. Elevation of the optic chiasm via a transnasal transsphenoidal approach with ALLODERM graft and septal cartilage strut was performed. The patient was discharged home the next day with significant improvement in vision; magnetic resonance imaging showed interval elevation of the optic chiasm., Conclusions: We review secondary empty sella syndrome and discuss surgical strategies for optic chiasmapexy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Chiasmapexy is used to treat empty sella syndrome, and various materials are used for the elevation of the optic chiasm. However, the use of artificial substances may have the risk of graft infection, and fat and muscle may be absorbed over the long term after surgery. In addition, bone and cartilage may be unavailable in adequate amounts. Here, we describe a new technique for chiasmapexy using an iliac crest bone graft., Case Description: The first patient was a 71-year-old woman who had undergone transsphenoidal surgery twice for the treatment of pituitary adenoma and Rathke cleft cyst. The optic chiasm collapsed after the second surgery and her visual field worsened gradually. We performed chiasmapexy using fat, fascia, and a septal mucosal flap, but the optic chiasm did not remain in the normal position because of graft shrinkage. Finally, we used an iliac crest bone graft, which resulted in good visual function. The second patient was a 58-year-old man who was incidentally diagnosed with empty sella syndrome. The patient's bitemporal hemianopia gradually progressed. As in the first case, we used an iliac crest bone graft, which halted the deterioration of visual function after chiasmapexy., Conclusions: The advantages of iliac bone are that it is less likely to absorb and become infected than synthetic materials. This method may be suitable for reoperative cases, especially those wherein the septal cartilage has been removed in a previous surgery. This method will halt visual deterioration and may be one of the considerable options for chiasmapexy operations., (Copyright © 2017 Elsevier Inc. All rights reserved.)