Nontraumatic ethmoid cerebrospinal fluid rhinorrhea complicating Sheehan syndrome

Treatment of pituitary macroadenoma frequently leads to nontraumatic cerebrospinal fistula and rhinorrhea. We report an unusual case of rhinorrhea in a woman with Sheehan's syndrome. A 39-year-old woman receiving hormone replacement therapy for hypothyroidism diagnosed 13 years earlier (Sheehan's syndrome) developed metabolic syndrome, which combining obesity, type 2 diabetes, hypertension and mixed hyperlipidemia. Cerebrospinal fluid rhinorrhea was confirmed by measurement of the glucose concentration in her nasal discharge and by cerebral MRI, which revealed a fistula of the ethmoid bone and an empty sella. Etiological screening was negative, and normal bone densitometry as well as the absence of trauma ruled out any bone defects. Conversely, the metabolic syndrome, notably obesity, suggested a nontraumatic mechanism for the empty sella. Onset of empty sella syndrome during treatment for Sheehan's syndrome may be the cause of the CSF rhinorrhea. The role of obesity requires further investigation.