Visual Vignette

Abstract

Case Presentation: A 37-year-old woman with a background history of hypertension presented with chronic headache and visual blurring. On examination, she was overweight (body mass index, 27 kg/m2), her blood pressure (BP) was 170/120 mm Hg, and she had no neurologic deficit. Her visual acuity was diminished, with enlarged blind spot bilaterally. Funduscopic examination (Fig. 1) revealed mildly engorged retinal veins, hyperemic swollen discs, and cotton wool exudates consistent with hypertensive retinopathy. Computed tomography of the brain was normal. A diagnosis of hypertensive emergency was made. Persistent headache despite controlled BP prompted a magnetic resonance imaging (MRI) scan of the brain. After the MRI, she was referred to the endocrinologist for an apparent empty sella. Figure 2 A and B shows an enlarged sella with a rim of normal pituitary tissue seen at the base of the sella, without any mass lesion, dural sinus thrombosis, or enlarged ventricles. Re-assessment indicated she had regular menses, normal complete blood count and serum electrolytes, including serum corrected calcium, 9.0 mg/dL (normal, 8.8 to 10.4 mg/dL), with an early morning cortisol, 14.8 μg/dL (normal, 5.2 to 22.3 μg/dL); free thyroxine, 1.2 ng/dL (normal, 0.8 to 1.8 ng/dL); thyroid-stimulating hormone, 0.9 mIU/L (normal, 0.5 to 4.8 mIU/L); insulin-like growth factor 1, 175 ng/mL (normal, 109 to 284 ng/mL); estradiol, 53.9 pg/mL (normal, 19 to 144 pg/mL); luteinizing hormone, 1.7 IU/L (normal, 0.5 to 16.9 IU/L); follicle-stimulating hormone, 2.6 IU/L (normal, 1.5 to 9.1 IU/L); and prolactin, 15.9 ng/mL (normal, 2.8 to 29.5 ng/mL). Lumbar puncture demonstrated an elevated opening pressure of 47 cm H2O (normal, <25 cm H2O for overweight/obese), with normal cerebrospinal fluid (CSF) composition. What is the diagnosis? Fig. 2 View Large Image Figure Viewer