Two cases of empty sella syndrome with variable dexamethasone-suppressibility of ACTH and cortisol

We here describe two patients with empty sella syndrome who had variable and abnormal ACTH and cortisol secretory profiles. The patients are a 58-year old male and a 41-year old female, both of whom were neurotic. In both cases, low-dose dexamethasone suppression tests (1 mg, p.o., overnight) caused variable responses, such as a paradoxical increase, insufficient decrease or normal decrease in ACTH and cortisol depending on the period when they were performed. The circadian rhythm of ACTH and cortisol also showed variable patterns. Abdominal CT showed slight enlargement of both adrenal glands. Adrenal scintigraphy after dexamethasone suppression (3 mg, p.o., 7 days) revealed uptake into both adrenal glands. MRI of the brain indicated empty sella, but failed to show evidence of pituitary adenoma. It remains to be elucidated whether these secretory profiles of ACTH and cortisol in the two cases are only to be regarded as secondary changes associated with neurosis, as reported in depression or alcoholism, or the two cases share some pathogenetic mechanism with cyclic Cushing disease.