# Adrenocorticotropic Hormone-Secreting Pituitary Microadenoma Presenting with Acute Psychosis, Delirium and Paroxysmal Sympathetic Hyperactivity

## TL;DR

A 42-year-old woman with a pituitary tumor experienced acute psychosis and delirium, which resolved after surgery.

## Contribution

This case highlights the rare acute psychiatric presentation of ACTH-secreting pituitary microadenoma.

## Key findings

- The patient showed acute behavioral changes consistent with psychosis and delirium due to Cushing’s disease.
- Symptoms resolved post-surgery with improved blood pressure and glucose control.
- Paroxysmal sympathetic hyperactivity was observed and managed with midazolam and levetiracetam.

## Abstract

Adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas are known to be associated with behavioural changes but acute presentation including psychosis and delirium are less common. We report the case of a 42-year-old female patient with a known medical history of hypertension and diabetes mellitus, presenting with acute onset behavioural changes suggestive of psychosis to a tertiary care centre in Muscat, Oman in 2022. 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 in addition to delirium. She also developed episodes of unresponsiveness, posturing, severe diaphoresis and dyspnoea accompanied by tachycardia and hypertension which were managed with midazolam and levetiracetam. A seizure work-up and computed tomography brain scan were unremarkable. At follow-up, she showed full resolution of symptoms with good blood pressure and glycaemic control.