Endocrine Abstracts

Introduction: Sheehan syndrome (SS) is caused by postpartum necrosis of the pituitary gland, associated with significant haemorrhage during or after delivery. It is rare in developed countries, but still frequent in underdeveloped ones. We present a rare presentation of this syndrome.

Clinical case: A 48 years old black woman presented at the emergency department for long term fatigue and dyspnea that worsened a few days before. Her physical examination revealed muffled heart sounds, decreased breath sounds inferiorly and bilaterally, a puffy face and dry skin. Also, she had a slurred speech and hoarseness. No other significant findings. No relevant past medical history, except for a complication in her second pregnancy (at 17 years), with a significant internal haemorrhage at term and an emergency caesarean section (stillborn). No subsequent lactation. Amenorrhea since then. Blood tests: Hb 9.3 g/dl (microcytic, hypochromic anaemia); LDH 1778UI/; CK 6793UI/L; AST 401UI/L; ALT 168UI/L; AF 366UI/L; total cholesterol 366 mg/dl; LDL 293 mg/dl; triglycerides 218 mg/dl. Arterial blood gas analysis: hypoxemia and slight hypercapnia. Chest x-ray: bilateral pleural effusion and cardiomegaly. Abdominal ultrasound: cholelithiasis. EKG: low QRS voltage. Echocardiogram: severe bilateral ventricular systolic dysfunction raised filling pressures on the left, enlarged atriums and pericardial effusion. Heart coronarography: no evidence of coronary artery obstruction. Her thyroid function tests were suggestive of central hypothyroidism (TSH 0.70 mU/L; FT4 <0.24). Pituitary functions test reaveled panhypopituitarism (FSH 4.1 UI/L; LH 2.6 UI/L; Estrogen<10 pg/ml; Testosterone <10 ng/dl; prolactin 0.8 ng/ml, IGF1). ACTH was not reliable because the patient had been started on corticosteroids before L-thyroxine. Sellar MRI showed an empty sella. Given her medical history in this clinical setting we believe a SS, left undiagnosed for 21 years, caused the panhypopituitarism.

Conclusion: This case is illustrative of a rare presentation of SS, with severe heart failure and low prolactin levels (unusually found).