How does a pituitary result in a psychiatric emergency? Read more clues to this clinical puzzle.
WHY PSYCHIATRISTS ARE PHYSICIANS FIRST
The EMS report was crystal-clear, but Elena’s diagnosis remained opaque even on the day of discharge. Let me explain how this happened. The hospital social worker telephoned at mid-morning, desperate for a same-day outpatient appointment for a woman aged about 50, “a stockbroker or something.” Managed care found “no medical necessity” for another day’s hospital stay now that Elena’s sensorium had cleared with antipsychotic medication. The patient refused to risk a hospital bill after her carrier refused coverage. So she had to leave the hospital NOW.
The social worker confessed confusion about Elena’s so-called “Psychosis NOS.” Toxicology screens were negative. Routine labs showed no uremia, no electrolyte imbalance, no liver disease. Vital signs were stable; temperature was normal. According to the social worker, the treating physicians had no explanation for Elena’s altered mental state. Yes, they had considered a cerebrovascular accident-but a CT scan without contrast was negative.
The radiologist’s report was reassuring. There was “no evidence of intracranial hemorrhage, acute large vessel infarct, or mass effect or midline shift. The cisternal spaces are preserved. The ventricles and subarachnoid spaces are normal in size. The visualized paranasal sinuses and the mastoid air cells are clear. The osseous structures are intact.” No mention was made of the sella turcica, which might have been telling.
In short, Elena’s microadenoma did not show up on a CT scan, even though many prolactinomas can be diagnosed by CT.1 Elena, in her disorganized state, could not provide a coherent history in the ED and the admitting attending abandoned efforts at obtaining an ROS, writing, “not available”; “confused historian.” So no one knew about her pituitary tumor-or its treatment-at the time of admission.
The social worker read me the EMS report: a security guard outside the Stock Exchange spotted a woman circling the big bull, not staggering, but distracted and unable to answer questions coherently. She looked vaguely familiar, the guard said, and was not in a state of disarray, like so many mentally ill people who wander around New York City. So, he called EMS.
According to the ED report, Elena muttered to invisible companions-while wearing a perfectly pressed Burberry coat and otherwise looking like a “financial type.” The ED attending suspected sleep deprivation, perhaps aided by Red Bull, but waited for toxicology screens to rule out excessive Adderall or cocaine use, said to be endemic around Wall Street.
Elena was admitted to the psychiatry unit, where risperidone was prescribed. After a few days, her speech became more organized, and she was able to recall that she had a prolactinoma, diagnosed many years earlier. More recent recall was still spotty. According to the chart, the information about the prolactinoma prompted a curbside consult with endocrinology, which recommended stopping the risperidone, which increases prolactin, and switching to aripiprazole, which counters hyperprolactinemia.
Elena arrived at my office, looking scared but not confused, like the person described in the EMS/ED notes. She was completely coherent and an impressive historian who spoke in accented English. She had faxed her insurance information before her appointment and listed “cabergoline toxicity???” as the reason for her consult. And then the story unfolded.
In the time between her hospital discharge and her appointment with me, Elena returned home, emptied her medicine cabinet, and found a nearly new bottle of cabergoline-the key to the mysterious psychosis. She stood the bottle upright on her sign-in sheet and wrote “cabergoline toxicity.”
Elena was eager to fill in whatever details she recalled. She had a pituitary tumor, supposedly asymptomatic until the cure became worse than the disease. A Russian Ã©migrÃ©, she lived and worked near Wall Street, where skyscrapers reach toward the stars and where hopes for the “American dream” run just as high. She was born to educated engineers who emigrated in pursuit of religious freedom (and economic advantages). Her father died soon after arrival in the US. Her mother, unable to master English, cleaned offices at night while Elena completed her MBA.
Elena smiled as she described Wall Street’s big iron bull, visible from her panoramic office window and even from her nearby apartment. She loved her adopted American culture, but suspected that her strong Russian accent stymied promotions and wondered if communication lapses impeded an earlier diagnosis (but dropped that idea when she saw her hospital report).
She said that she preferred emails and spreadsheets to conversations, which worked out well for her line of work. Like many Wall Street analysts and attorneys, she holed up in her office for days on end, crunching numbers non-stop. Apparently, no one was concerned when she did not emerge all weekend. She could not recall what happened after her last meal delivery, and when she was found wandering around Wall Street.
Elena had hit the diagnosis on the head. She was “right on the money,” in more ways than one. Everything made sense after she mentioned her pituitary tumor and the bottle of cabergoline.
Elena’s endocrinologist had recently upped her cabergoline dosage (which she did not recollect until she eyeballed the prescription bottle and read the fine print). A delirium and visual hallucinosis followed, which was not surprising, considering that both cabergoline and LSD derive from ergot, an ancient grain fungus that enjoyed many medicinal uses over the centuries. Shrinking pituitary tumors and treating Parkinson disease are more recent applications, but the herbal was once a midwife’s favorite, used to stop postpartum bleeding, to induce delayed menses, and as an abortifacient.
Elena’s prognosis sounded less ominous after we traced her acute mental status changes to a specific source. I contacted her endocrinologist. He said that he preferred slightly elevated prolactin levels over emergency psychiatric admissions. He opted for the time-honored tradition of “watchful waiting” before trying new medications. Elena’s concentration problems, present for the first few months, gradually abated. Half a year later, when no symptoms emerged, we cautiously lowered her aripiprazole dose.
But, there’s more to this story. At the lower dose of 5 mg of aripiprazole, Elena realized that she had lost that “restless feeling.” A coworker suggested that she moved like a floor trader, rather than a back-office analyst, and now we knew why: aripiprazole-induced akathisia. Elena was eager to stop the aripiprazole altogether. And that is what we did. With her mental status stable, there was nothing to lose but the adverse effects-or so it seemed. However, one side effect was gone. Without aripiprazole, her prolactin skyrocketed past 100.
Elena refused to restart cabergoline or bromocriptine, given her past experiences. Restarting low-dose aripiprazole to control her prolactinoma was not part of the plan-but a review of the medical literature made the plan seem more promising. Some endocrinology journals reported success in treating pituitary adenomas with aripiprazole.2,3 It was not a first-line treatment, but it seemed better than no treatment at all. With the endocrinologist monitoring prolactin levels, the ophthalmologist measuring visual fields, the radiologist following the size of the adenoma, and me monitoring her mental status and movements, it was a plan that could be reassessed and revised as needed.
It is cases like Elena’s that make it hard to imagine practicing psychiatry without having studied medicine first. Another good reason why psychiatrists are physicians first.
Dr. Packer is affiliated with Mount Sinai Beth Israel and has a private practice in Soho, New York City. Her most recent book is Neuroscience in Science Fiction Films (2015). Her book Mental Illness in Popular Culture is in press and scheduled for release this summer.
1. Marcovitz S, Wee R, Chan J, Hardy J. Diagnostic accuracy of preoperative CT scanning of pituitary prolactinomas. Am J Neuroradiol. 1988;9:13-17.
2. Bakker ICA, Schubart CD, Zelissen PMJ. Successful treatment of a prolactinoma with the antipsychotic drug aripiprazole. Endocrinol Diabetes Metab Case Rep. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898067/. Accessed April 6, 2017.
3. Wix-Ramos RJ, Paez R, Capote E, Ezequiel U. Pituitary microadenoma treated with antipsychotic drug aripiprazole. Recent Pat Endocr Metab Immune Drug Discov. 2011;5:58-60.