Endocrine Abstracts

Introduction: Sheehan’s syndrome is hypopituitarism occurring due to pituitary infarction secondary to severe post-partum haemorrhage. Here, we are presenting an interesting case history of Sheehan’s syndrome diagnosed 15–20 years after its onset.

Case history: A 47-year-old lady attended emergency room (ER) with recurrent episodes of nausea, vomiting and dizziness on standing. Initial evaluation revealed hypotension and the random serum cortisol was 0.22 mg/dl. Adrenal insufficiency was diagnosed and suspected to be due to systemic tuberculosis diagnosed a few months ago. She was started on oral hydrocortisone and discharged from ER.

She returned to endocrinology OPD 10 months later with similar symptoms. PMH revealed that she delivered her last child at home. She had severe bleeding during and after delivery. Lactation was impaired and she remained amenorrhoic since then. Biochemistry revealed ACTH 3.63 pg/ml (7.2–63.3), FT₄ 0.31 ng/dl (0.89–1.76), TSH 6.51 μIU/ml (0.35–5.5), LH 3.91 mIU/ml (8.0–33.0), FSH 9.9 mIU/ml (17–95), prolactin 4.3 ng/ml (5.0–35), sodium127 mEq/l (135–150), potassium3.7 mEq/l (3.5–5.0), hemoglobin 9.5 gm/dl, and 0800 h cortisol 0.67 μg/dl (4.30–22.40). MRI scan of the pituitary revealed partial empty sella. She was diagnosed to have pan-hypopituitarism. She has been started on oral hydrocortisone, thyroxin and HRT was deferred because of menopausal age.

Conclusion: The prevalence of Sheehan’s syndrome has reduced significantly in developed countries but is still prevalent in developing countries. Adrenal insufficiency was the presenting symptom in this patient. As she had been diagnosed with tuberculosis, the adrenal insufficiency was thought to be primary and not due to pituitary cause. But with further probing and detailed history taking, the underlying cause and associated problems were found. Detailed history taking and high index of suspicion for pituitary causes are still the most important aspects of clinical practice.