We report a case of a 27 yr female patient who initially presented with jaundice at 38 weeks gestation, with biochemical transaminitis. She had a caesarean section which was complicated postoperatively by hypotension due to haemorrhage requiring 20 units of blood/blood-products. A specialist liver unit felt the jaundice was secondary to fatty liver of pregnancy. She had difficulty breastfeeding and 18 months post partum she still had secondary amenorrhea so was commenced onto oestrogen replacement, without any endocrine investigations. At the age of 32 yr she presented to our hospital due to a collapse. Over the previous 2 years she had noticed a marked deterioration in her health and had several visits to her GP complaining of tiredness and dizziness; 1 week prior to admission she had been vomiting on a regular basis. Her blood pressure in A&E was 80/40 mmHg and biochemically her glucose was 0.8 mmol/l, sodium 123 mmol/l and potassium 4.6 mmol/L. Under the admitting team, she was treated with 10-20% dextrose infusions, but she still remained hypoglycaemic and hypotensive without any clear management plan. Two days later endocrine advice was sought and further tests revealed a 9 am cortisol 24 nmol/l, 9 am ACTH <10 ng/l, prolactin 16 mu/L, free T4 2.4 pmol/L (11.023.3), TSH 1.61 mu/L, IGF1 58.0 ng/ml (120330). Following a synacthen test, the cortisol was 103 nmol/l at 60 minutes, so she was commenced initially onto hydrocortisone and then thyroxine replacement, with a dramatic improvement in her clinical status. A clinical diagnosis of Sheehan syndrome was made and a MRI showed an empty sella. Currently aged 43 yr, she is on hydrocortisone, thyroxine and oestrogen replacement and is being assessed for growth hormone therapy. Hypoglycaemia is a common problem seen in emergency departments, however our case shows that rarer endocrinological causes, which can be life threatening, need to be considered in patients not on previous therapy for diabetes mellitus.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.