Sheehan’s syndrome as a rare cause of anaemia secondary to hypopituitarism

A Case Report of Hemolytic Hyponatremia

Hereditary spherocytosis/elliptocytosis is a non-immune hemolytic anemia caused by an alteration in the erythrocyte membrane that predisposes the cell to its lysis. This report presents a case of a 42-year-old woman with a history of spontaneous abortion, associated with postpartum bleeding, chronic anemia, and premature menopause. After five years, she consulted due to alterations in the state of consciousness and severe symptomatic hyponatremia, with a diagnosis of hypopituitarism, explained by a late Sheehan syndrome. During hospitalization, she developed non-immune hemolytic anemia associated with a positive osmotic fragility test. A diagnosis of hereditary spherocytosis/elliptocytosis was made. We correlate blood hypoosmolarity as a trigger with the in vitro hypotonic solution of the osmotic fragility test for the diagnosis of this disease. This association is not reported in the literature; in our case, we show the concomitant improvement of anemia with the increase in sodium levels and hormonal replacement.

Anterior hypopituitarism due to primary empty sella syndrome in a critically unwell patient

A previously fit and well male in his early 40s, presented to the emergency department, hypotensive, bradycardic and hypothermic with reduced levels of consciousness after being found diaphoretic and unwell at his home. Despite fluid resuscitation with warmed saline, he remained hypotensive and required vasopressor support leading to intensive care admission. Initially, the patient was managed for suspected meningoencephalitis but was later found to have hypopituitarism leading to secondary hypothyroidism and adrenal insufficiency. Subsequent investigations revealed it is due to empty sella syndrome.

Acute pituitary crisis after lumbar surgery: A case report

RATIONALE

Patients with hypopituitarism often have no specific symptoms; that frequently results in missed diagnosis. An acute hypopituitarism crisis can be induced under stressful conditions. Here, we report a rare case of an acute pituitary crisis after lumbar surgery.

PATIENT CONCERNS

We describe a 62-year-old female who presented with refractory electrolyte disorders after lumbar surgery. In addition, she developed anorexia, nausea, vomiting, chest cavity effusion, ascites, pericardial effusion, anemia, low blood pressure, bradycardia, and unconsciousness after surgery. MRI showed an empty sella turcica.

DIAGNOSES

She was diagnosed with postoperative acute hypopituitary crisis.

INTERVENTIONS

The patient received hormone replacement therapy.

OUTCOMES

Her symptoms improved significantly following the initiation of hormone replacement therapy and was well 6 months after surgery.

LESSONS

Refractory postoperative complications, including electrolyte disorders, infection, nausea, vomiting, circulatory collapse, anemia, and coma, indicate an acute postoperative hypopituitary crisis.

From acute abdomen to hormonal crisis: Case report on a long-delayed Sheehan's syndrome diagnosis

INTRODUCTION

Sheehan's syndrome (SS) is a rare cause of hypopituitarism resulting from postpartum haemorrhage and pituitary necrosis. It remains an underdiagnosed condition, especially in developing countries due to poor obstetric care and home deliveries. This case report highlights the significance of recognizing atypical presentations of SS, such as pancytopenia, to aid in early diagnosis and management.

CASE PRESENTATION

A 40-year-old female presented with acute abdomen symptoms and was initially diagnosed with acalculous cholecystitis. However, a detailed history revealed a history of postpartum haemorrhage 18 years prior, leading to a provisional diagnosis of SS. Further investigations confirmed panhypopituitarism, including hypothyroidism, hypocortisolism, and hypogonadism. Notably, the patient also exhibited pancytopenia, a rarely reported haematological manifestation of SS.

DISCUSSION

SS often presents with nonspecific symptoms, leading to delayed or missed diagnoses. In this case, the patient's initial presentation of acute abdomen symptoms was attributed to secondary adrenal insufficiency due to panhypopituitarism. The presence of pancytopenia, along with hyponatremia, further complicated the clinical picture. Hormone replacement therapy led to a remarkable improvement in the patient's condition, emphasizing the importance of early diagnosis and intervention.

CONCLUSION

SS is a common cause of panhypopituitarism in developing countries, but its atypical presentations, such as pancytopenia, are rare and often overlooked. This case highlights the need for increased awareness among clinicians to consider SS in patients with unexplained haematological abnormalities, particularly in regions with high rates of postpartum haemorrhage. Early recognition and appropriate hormone replacement therapy can significantly improve patients' outcomes and prevent long-term complications associated with this underdiagnosed syndrome.

A rare case of pancytopenia causing- Sheehan's syndrome: Case report and literature review

We describe the case of a 58-year-old woman who was presented with pancytopenia and hypofibrinogenemia. Treatment with iron supplementation was not satisfactory. Physical findings and a history of a massive postpartum hemorrhage suggested Sheehan's syndrome(SS). After thyroxine and glucocorticoid replacement therapy, the blood cell count improved. SS is a rare etiology of hemocytopenia, of which hematologists need to be aware. We conclude that hormonal therapy can produce full hematological recovery.

Case report: Pancytopenia as a rare presentation of Sheehan’s syndrome

Sheehan’s syndrome is a postpartum hypopituitarism state caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Sheehan’s syndrome symptoms are often subtle and hence it is diagnosed late. Herein, we report a case of a 41-year-old woman who developed severe postpartum hemorrhage after childbirth that required a total abdominal hysterectomy to control bleeding at the age of 36 years. Since then, she has progressively developed symptoms of headache, general fatigue, and malaise, and finally presented with pancytopenia for investigations. Anemia is a well-known hematological association with Sheehan’s syndrome while pancytopenia is rarely reported. However, complete recovery of pancytopenia was observed after the treatment. Pancytopenia (due to bone marrow failure to produce cells) is a serious finding in clinical practice that causes significant stress as it may point to a diagnosis of malignancy (mainly leukemia) and other serious disorders. Despite being a rare cause, a high index of suspicion is required from the physicians in women with pancytopenia, in order to look for a possible treatable cause of pancytopenia (like Sheehan's syndrome), if the common causes were excluded.

Clinical, Endocrine, Metabolic Profile, and Bone Health in Sheehan's Syndrome

BACKGROUND

Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis resulting from severe postpartum hemorrhage (PPH). SS is characterized by varying degrees of pituitary insufficiency involving mostly the anterior lobe. Comprehensive data on SS apart from endocrine dysfunction is scarcely available.

MATERIALS AND METHODS

Thirty-eight subjects previously diagnosed with SS were enrolled in this observational study. Their clinical, biochemical, hormonal, radiological data at presentation were recorded from past records and bone density was measured in all.

RESULTS

Mean (±SD) age was 39 (±8.7) years and diagnostic delay was 9.3 (±5.5) years. All had history of PPH and lactation failure. About 47% were referred from emergency, and rest 53% were diagnosed from outpatient's department. Mean free T4, TSH, prolactin, morning cortisol, FSH, LH, and IGF-1 were mostly low. Panhypopituitarism was present in 97%. Hyponatremia was most common electrolyte imbalance found in about 53%. More than 40% had elevated transaminases. Dyslipidemia especially low HDL was found in 31 (81.5%) subjects. MRI of hypothalamus-pituitary region showed empty sella in 53% and partial empty sella in 47%. About 13% subjects had diabetes mellitus. Low bone mass (BMD Z-Score ≤-1) was seen in 80% and it was more severe (BMD Z-Score ≤-2) in 44% subjects, affecting predominantly lumbar spine. Bone loss at femoral neck was less prominent.

CONCLUSION

Apart from variable spectrum of clinical presentation, subjects with SS have significant abnormalities in serum electrolytes, metabolic parameters. Low bone mass is also a frequent accompaniment.

Sheehan syndrome

Sheehan syndrome or postpartum hypopituitarism is a condition characterized by hypopituitarism due to necrosis of the pituitary gland. The initial insult is caused by massive postpartum haemorrhage (PPH), leading to impaired blood supply to the pituitary gland, which has become enlarged during pregnancy. Small sella turcica size, vasospasms (caused by PPH) and/or thrombosis (associated with pregnancy or coagulation disorders) are predisposing factors; autoimmunity might be involved in the progressive worsening of pituitary functions. Symptoms are caused by a decrease or absence of one or more of the pituitary hormones, and vary, among others, from failure to lactate and nonspecific symptoms (such as fatigue) to severe adrenal crisis. In accordance with the location of hormone-secreting cells relative to the vasculature, the secretion of growth hormone and prolactin is most commonly affected, followed by follicle-stimulating hormone and luteinizing hormone; severe necrosis of the pituitary gland also affects the secretion of thyroid-stimulating hormone and adrenocorticotropic hormone. Symptoms usually become evident years after delivery, but can, in rare cases, develop acutely. The incidence of Sheehan syndrome depends, to a large extent, on the occurrence and management of PPH. Sheehan syndrome is an important cause of hypopituitarism in developing countries, but has become rare in developed countries. Diagnosis is based on clinical manifestations combined with a history of severe PPH; hormone levels and/or stimulation tests can confirm clinical suspicion. Hormone replacement therapy is the only available management option so far.

Four decades without diagnosis: Sheehan's syndrome, a retrospective analysis

AIM

Sheehan's syndrome (SS) remains a frequent cause of hypopituitarism in undeveloped and developing countries, but due to improvements in obstetric care, it is rare in developed countries. We aimed to share the results of a retrospective study analyzing the demographic, clinical, imaging, and hormonal characteristics of a large group of patients with SS, and also increase awareness of this syndrome especially in developed countries.

METHODS

The medical records of 124 patients with SS patients who were followed up in the Endocrinology Department of Dicle University between 1995 and 2015 were assessed retrospectively.

RESULTS

The mean period of diagnostic delay was 20.37 ± 8.34 years on average. 5.7% of patients with SS were literate; 62% of patients delivered at home. Anemia was identified in 64.5% of SS patients. Mean blood sodium levels were 129.8 ± 11.3 mEq/L. The mean urine densities were 1013 ± 6.5. Osteoporosis and osteopenia were found in 44 (35.4%) and 71 (57.2%) patients, respectively, According to pituitary magnetic resonance imaging (MRI) analyses, 92 (74.2%) patients with SS had completely empty sella, 29 (23.3%) had partially empty sella, and 1 patient had microadenoma, and 2 had normal pituitary MRI results.

CONCLUSIONS

Improved obstetric care and effective interventions for postpartum hemorrhage have limited the prevalence of SS in developed countries. However, in developing countries like Turkey, SS due to postpartum bleeding remains common. Thus, physician's awareness of the symptoms of SS is urgently required to avoid the associated morbidity and mortality.

Hormones and the bone marrow: panhypopituitarism and pancytopenia in a man with a pituitary adenoma

In rare cases, pancytopenia results from hormonal deficiencies that arise in the setting of panhypopituitarism. Here we describe the unusual case of a 60-year-old man who presented with progressive fatigue and polyuria, and whose laboratory workup revealed a deficiency of the five hormones associated with the action of the anterior pituitary (thyroid hormone, testosterone, cortisol, prolactin, and insulin-like growth factor-1). Imaging of the pituitary demonstrated a cystic mass consistent with a pituitary adenoma replacing much of the normal pituitary tissue. His symptoms and hematologic abnormalities rapidly resolved with prednisone and levothyroxine supplementation. While the majority of reported cases of panhypopituitarism with bone marrow suppression are the result of peripartum sepsis or hemorrhage leading to pituitary gland necrosis (Sheehan's syndrome), it is also important to consider the diagnosis of hypopituitarism in patients with hypothyroidism, low cortisol levels, and pancytopenia. The causal relationship between pancytopenia and panhypopituitarism is not well understood, though it does reinforce the important influence of these endocrine hormones on the health of the bone marrow.

Sheehan's syndrome

Sheehan's syndrome (SS) is characterized by various degrees of hypopituitarism, and develops as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. Increased pituitary volume, small sella size, disseminated intravascular coagulation and autoimmunity are the proposed factors in the pathogenesis of SS. Hormonal insufficiencies, ranging from single pituitary hormone insufficiency to total hypopituitarism, are observed in patients. The first most important issue in the diagnosis is being aware of the syndrome. Lack of lactation and failure of menstrual resumption after delivery that complicated with severe hemorrhage are the most important clues in diagnosing SS. The most frequent endocrine disorders are the deficiencies of growth hormone and prolactin. In patients with typical obstetric history, prolactin response to TRH seems to be the most sensitive screening test in diagnosing SS. Other than typical pituitary deficiency, symptoms such as anemia, pancytopenia, osteoporosis, impairment in cognitive functions and impairment in the quality of life are also present in these patients. Treatment of SS is based on the appropriate replacement of deficient hormones. Growth hormone replacement has been found to have positive effects; however, risk to benefit ratio, side effects and cost of the treatment should be taken into account.

Hematological response of pancytopenia to glucocorticoids in patients with Sheehan's syndrome

Sheehan's syndrome presents with panhypopituitarism after childbirth, usually preceded by post partum hemorrhage. Hematological abnormalities like pancytopenia with hypocellular marrow in these patients are reported rarely. Though multiple hormone deficiencies may contribute to Pancytopenia in Sheehan's syndrome, complete recovery is observed after achieving eucortisolemic and euthyroid state. The predominant role of thyroxine or glucocorticoids in reversing pancytopenia in these patients has not been studied. We present the clinical, hormonal, hematological course and response to glucocorticoids in a patient of Sheehan's syndrome presenting with pancytopenia. Complete recovery of pancytopenia was observed after achieving eucortisolemic state thus concluding that gulcocorticoid replacement is sufficient to reverse pancytopenia in these patients.

Sheehan's syndrome with pancytopenia: a case report and review of the literature

INTRODUCTION

Sheehan's syndrome is defined by varying degrees of anterior pituitary deficiency due to postpartum ischemic necrosis of the pituitary gland after massive bleeding. It is a rare disorder in western countries and even in Tunisia. Hematologic abnormalities such as normochromic anemia have been reported in these patients. However, pancytopenia is rarely observed.

CASE PRESENTATION

We describe the case of a 48-year-old Tunisian woman with features of hypopituitarism. Laboratory tests showed pancytopenia that was completely reversed after adequate hormone replacement.

CONCLUSION

Clinicians should consider the possibility of hypopituitarism as a cause of pancytopenia. This is an original case report that is of interest to hematologists, who should be aware of Sheehan's syndrome as a treatable etiology of pancytopenia for women.

Prevalence of hematological abnormalities in patients with Sheehan's syndrome: response to replacement of glucocorticoids and thyroxine

Anemia and other hematological abnormalities are common in patients with Sheehan's syndrome. The response of these abnormalities to replacement of thyroxine and glucocorticoids is not clear. The aim of the present study was to document the profile of hematological abnormalities and response to treatment in patients with Sheehan's syndrome. Forty patients of Sheehan's syndrome and an equal number of age and parity matched healthy controls were studied for prevalence of hematological abnormalities. Hemoglobin concentration, hematocrit, red cell, white cell and platelet count were significantly decreased in patients with Sheehan's syndrome compared to controls. Frequency of anemia, leucopenia, thrombocytopenia and pancytopenia was significantly higher in these patients compared to controls. After achieving euthyroid and eucortisol state, there was a complete recovery of these hematological abnormalities. We conclude that anemia and other cytopenias are common in patients with Sheehan's syndrome and replacement with thyroxine and glucocorticoids results in complete recovery of these abnormalities.