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A Case of Sheehan's Syndrome
 

A Case of Sheehan's Syndrome

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    A Case of Sheehan's Syndrome A Case of Sheehan's Syndrome Presentation Transcript

    • INTERESTING CASE OF ANAEMIA S.DHANRAJ PG M2 DR.SUNDARAMURTHY’S UNIT
    • • 40 YRS OLD MRS.SARASU CAME WITH C/O on 4/4/13 Decreased urine output – 15 days -- gradual -- 300ml/day Abdominal pain -- 6 months -- pricking,more towards epigastric region,not radiating or referred,not assoc. with any other symptoms Fever -- on and off,10 days -- low grade intermittent, not assoc. with chills,rigor,rash,bleeding tendency
    • • Leg swelling -- 15 days -- bilateral,upto knee No h/o abdominal distention No h/o constipation No h/o chest pain/ breathlesness No h/o jaundice h/o hair fall + h/o easy fatigueability+ h/o loss of apetite No h/o contact No h/o trauma No h/o loc, no h/o drug intake
    • • PAST HISTORY Not a known DM/SHT/CAD No previous admissions • MENSTRUAL HISTORY amenorrhea for 18 yrs
    • EXAMINATION Drowsy Temperature (98.4 F ) dehydrated, Severe pallor,facial puffiness Dry coarse skin,sparse hair in scalp Hoarse voice b/l pedal edema+ no clubbing,no palpable lymphadenopathy
    • CVS – s1s2+ RS -- B/L normal breath sounds P/A– epigastric tenderness+ -- no organomegaly CNS – drowsy ,responding to oral commands -- Examination: able to move all four limbs -- delayed DTR VITALS : BP-90/60mmHg; PR- 60/min
    • • She was initially suspected as a case of ? Chronic kidney disease with encephalopathy and fever under evaluation
    • • INVESTIGATIONS • CBC – HB 7.6 SR. ELECTROLYTES TC 4500 Na-129 DC N70L27E3 K-3.7 ESR 15/35 CL-98 PCV 24 HCO3-23 MCV 83 URINE MCH 26 ALB-NIL MCHC 31 SUG-NIL RBC 2.8LAC DEP-1-3PUS CELLS PLATLETS 1L • RFT- SUGAR 203 UREA 12 CREATININE 0.8
    • • USG– N STUDY • CXR- PA – N STUDY • ECG -- WNL • ECHO -- N LV FUNCTION • FEVER PROFILE AND BLOOD CULTURE-- NEGATIVE
    • • CLINICALLY , suspected MYXEDEMA PRECOMA TFT SENT and  started on ELTROXIN 100mcg WITH steroids
    • TFT results– FT3 - 0.37pg/ml(2.3 to 4.2pg) FT4 – 0.41ng/dl(0.6 to 2ng) TSH – 2.572miu/ml(1 to 5miu/ml) ELTROXIN dose stepped up
    • INVESTIGATIONS • 5/4/2013 Urine spot PCR– 23/13 p.smear– microcytic hypochromic anaemia Wbc—N Platelets– adequate No immature cells/haemoparasite
    • • Reticulocyte count – 1.5% (0.5-1.5%) • • Se LDH 190 U/L (135-220) • Coomb’s test: negative • Serum iron: 48 (50 to 150mcg/dl) • TIBC: 380 (300-360 mcg/dl) • Serum ferritin : 28 (30 to100mcg/dl)
    • • 7/4/13 patient started showing improvement FURTHER INVESTIGATIONS With TFT results (low t3, t4, normal TSH) a pituitary cause of hypothyroid was suspected and PROCEEDED FOR workup for endocrine insufficiency
    • • PROLACTIN – 0.6ng/ml (4.7 to 23.3 ng) • LH – 0.99miu/ml ( Follicular phase:2.4-12.6 Ovulation phase:14-95.6 Luteal phase: 1-11.4 mIU/ml) • FSH – 3.14 miu/ml ( Follicular phase: 3.5-12.5 Ovulation phase: 4.7-21.5 Luteal phase: 1.7-7.7 mIU/ml) • CORTISOL – 0.42mcg/dl ( 6.2 – 19.4 mcg/dl) • ACTH – 3.07pg/ml (7.2 – 63.3 pg/ml)
    • • Patient was continued with Levothyroxine and steroids • Patient improved dramatically
    • ON PROBING She gave • h/o post partum haemorrhage at 3rd delivery • Lactation failure after 3rd delivery • Amenorrhea for 18 years • PROCEEDED WITH MRI BRAIN
    • FINAL DIAGNOSIS • EMPTY SELLA SYNDROME probably due to POSTPARTUM PITUITARY NECROSIS (SHEEHAN’S SYNDROME)
    • INVESTIGATIONS NOT DONE • Stimulation and provocative tests • Posterior pituitary hormones assay • Autoimmune work up----primary hypophysitis (lymphocytic, granulomatous) • Secondary hypophysitis—(infections, sarcoidosis, takayasu) • Haematological malignancy
    • SHEEHAN’S SYNDROME - Postpartum hypopituitarism 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 - Usually presents as anterior pituitary hormone deficiency - Evolves slowly and is diagnosed late
    • - most common cause of hypopituitarism in developing countries - prevalence to be about 3% for women above 20 years of age - average time between the previous obstetric event and diagnosis of SS was 6 to 13 years
    • MECHANISM • Ischemic pituitary necrosis due to severe postpartum hemorrhage • Vasospasm, thrombosis and vascular compression of the hypophyseal arteries • Autoimmunity
    • PRESENTATION
    • SYMPTOMS • CORTICOTROPIN DEFICIENCY can cause weakness, fatigue, hypoglycemia, or dizziness. • GONADOTROPIN DEFICIENCY will often cause amenorrhea, oligomenorrhea, hot flashes, or decreased libido. • GROWTH HORMONE DEFICIENCY causes many vague symptoms including fatigue, decreased quality of life, and decreased muscle mass. • Difficulty breast-feeding or an inability to breast-feed • HYPOTHYROIDISM • Some women live for years with pituitary insufficiency, can present as ADRENAL CRISIS triggered by extreme physical stressors, such as severe infection or surgery.
    • TREATMENT Hormone replacement • Hydrocortisone or prednisolone is replaced first because thyroxine therapy can exacerbate glucocorticoid deficiency and theoretically induce an adrenal crisis. • thyroxine replacement • gonadotropin replacement • Replacement of growth hormone is necessary in children with hypopituitarism but is controversial in adults.
    • REPLACEMENT • ACTH -- Hydrocortisone Cortisone acetate Prednisone • TSH – L-Thyroxine • FSH/LH -- Females Conjugated estrogen (0.65–1.25 mg qd for 25 days) Progesterone (5–10 mg qd) on days 16–25 For fertility: Menopausal gonadotropins, human CG Males Testosterone enanthate • GH -- Adults: Somatotropin (0.1–1.25 mg SC qd) Children: Somatotropin [0.02–0.05 (mg/kg per day)] • VASOPRESSIN
    • THANK YOU