Psychosis as the prominent presentation of pituitary apoplexy: a case report and literature review

Abstract Pituitary apoplexy is a neurosurgical and endocrine emergency classically characterized by sudden headache, visual impairment, and acute hypopituitarism. Psychiatric manifestations, particularly psychosis as the initial or predominant feature, are rare and may lead to diagnostic delay and mismanagement. We report a 19-year-old female with no prior medical or psychiatric history who presented with a three-month subacute course of behavioral and cognitive changes, culminating in first-episode psychosis. Laboratory investigations showed isolated hypocortisolism, with otherwise normal pituitary and thyroid function. Brain computed tomography demonstrated an enlarged pituitary gland with hyperdense material suggestive of pituitary apoplexy; however, magnetic resonance imaging (MRI), the gold standard for sellar evaluation, was not performed at initial presentation, limiting diagnostic certainty. Subsequent outpatient MRI suggested a lesion in the pars intermedia that may represent a Rathke cleft cyst; therefore, the case is best interpreted as suspected pituitary apoplexy. Subsequent ophthalmological assessment revealed visual field defects. The patient was treated with intravenous hydrocortisone followed by oral replacement, alongside olanzapine and clonazepam. This case illustrates that pituitary apoplexy may present primarily with psychosis, even in the absence of classical neurological or endocrine features, and with only subtle hormonal abnormalities such as isolated hypocortisolism. It also highlights the limitations of CT-based diagnosis in confirming pituitary apoplexy. Clinicians should maintain a high index of suspicion for organic etiologies in young patients with psychosis. This case, supported by a focused literature review identifying only a few similar reports, highlights the importance of early endocrine evaluation and targeted neuroimaging in atypical first-episode psychosis.