Endocrine Abstracts

JOINT2246

Introduction: Sheehan syndrome is hypopituitarism due to pituitary necrosis resulting from hemorrhagic choc during pregnancy. The clinical picture is characterized by post-partum amenorrhea and absence of lactation. Psychotic presentations are rare. This article reports an exceptional case of sheehan’s syndrome with a psychiatric presentation.

Case report: The patient was 65 years old, not known to have an endocrinopathy. She had been known to be diabetic for 24 years and was being followed for heart disease. She had been menopausal for 25 years following her last delivery, which was complicated by post-partum haemorrhage, absence of milk production and return from childbirth. Admitted to the emergency department, she presented with psychomotor agitation consisting of delusions of persecution and bizarre delusions, auditory and visual hallucinations, repetitive gestures and aggressive behaviour. This picture was preceded by asthenia and a digestive picture of abdominal pain, vomiting and diarrhea. Clinical examination revealed a disoriented patient, pale skin and mucous membranes, hypotension, depigmentation of the nipples, axillary and pubic depilation, and edema of the lower limbs. Biological tests revealed normocytic normochromic anemia with hemoglobin at 8g/dl, hyponatremia at 117mmol/l, 8 hour cortisol level at 2.9µg/dl, ultrasensitive thyroid stimulating hormone at 0.55mUI/l, T4L less than 5.15pmol/land T3 less than 1.64 pmol/l. Magnetic resonance imaging revealed an empty sella turcica. The patient underwent hormone replacement with glucocorticoids and thyroxine, with a spectacular evolution.

Discussion: The pathophysiology of the psychiatric manifestations of Sheehan syndrome is unclear. It seems to result from a complex interaction between hormonal deficiencies and metabolic and electrolyte changes in the central nervous system, such as hyponatremia. The latter is known to cause cognitive deficits and is not usually associated with psychotic symptoms in the absence of disturbances of consciousness and neurological signs. Hypothyroidism may play a more important role in pathogenesis, as it is systematically associated with neuropsychiatric manifestations. It is associated with mood symptoms rather than psychosis, although psychotic presentations without mood disorders have been reported. Dramatic improvement with glucocorticoids and thyroxine suggests a possible link with these hormonal deficiencies.

Conclusion: Psychosis in patients with Sheehan’s syndrome is uncommon. This rare presentation of Sheehan syndrome with psychosis not only represents the close association of organic pathology to psychiatric manifestations but also illustrates the possible psychiatric adverse effects of panhypopituitarism and its metabolic consequences. Clinicians should have a high index of suspicion in case of postpartum- psychosis presenting with significant obstetric history.