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Gupta R, Chaudhary S, Sood V, Chauhan NS, Chauhan N, Kapoor D. Acute parkinsonism in a patient with myxedema crisis: A case report. MEDICINE INTERNATIONAL 2024; 4:49. [PMID: 39006812 PMCID: PMC11240856 DOI: 10.3892/mi.2024.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024]
Abstract
Both myxedema crisis and Sheehan's syndrome are uncommon conditions. The first-time presentation as myxedema crisis is rare in Sheehan's syndrome. The present study describes the case of a 31-year-old female patient who presented with altered sensorium in the emergency room. The patient was not a known case of hypothyroidism, but had a history of secondary amenorrhea and lactation failure following the birth of a child 11 years prior. Upon evaluation, she was found to have hypothermia, hypotension, the delayed relaxation of deep tendon reflexes, bradycardia and hyponatremia, which led to the suspicion of myxedema crisis. Her thyroid function tests were suggestive of secondary hypothyroidism and her pituitary hormonal profile revealed panhypopituitarism. The patient was managed on the lines of myxedema crisis with oral levothyroxine, hydrocortisone infusion, antibiotics and rewarming. Her clinical and biochemical parameters exhibited an improvement; however, her altered sensorium persisted. A repeat neurological examination revealed cogwheel rigidity with paraparesis, which led to the clinical suspicion of acute parkinsonism. Magnetic resonance imaging of the sella and brain was suggestive of an empty sella and extrapontine myelinolysis, substantiating the diagnosis of Sheehan's syndrome with acute parkinsonism. The patient was commenced on levodopa-carbidopa following which there was an improvement in symptoms. The patient improved over the ensuing 6 months and can now perform all household activities. On the whole, the present study indicates that the early suspicion of myxedema crisis, prompt treatment and the recognition of additional aetiology for persistent altered sensorium can result in a successful outcome for the patient.
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Affiliation(s)
- Rajat Gupta
- Department of Medicine, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
| | - Shakun Chaudhary
- Department of Endocrinology, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
| | - Vivek Sood
- Department of Medicine, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
| | - Narvir Singh Chauhan
- Department of Radiology, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
| | - Nidhi Chauhan
- Department of Medicine, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
| | - Dhiraj Kapoor
- Department of Medicine, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh 176001, India
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Wang H, Gong X. Acute pituitary crisis after lumbar surgery: A case report. Medicine (Baltimore) 2023; 102:e36294. [PMID: 38050276 PMCID: PMC10695533 DOI: 10.1097/md.0000000000036294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hui Wang
- Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Xingrui Gong
- Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
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Partial Sheehan's syndrome with abdominal tuberculosis presented with pancytopenia and fluctuating thyroid profile: a case report. Ann Med Surg (Lond) 2023; 85:506-513. [PMID: 36923749 PMCID: PMC10010817 DOI: 10.1097/ms9.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/24/2022] [Indexed: 03/06/2023] Open
Abstract
Sheehan's syndrome is a well-recognized cause of panhypopituitarism secondary to pituitary apoplexy, followed by postpartum hemorrhage. Depending upon the degree of ischemic injury, it can be either partial or complete. Case presentation We report an interesting case of a 35-year-old woman admitted to our hospital with complaints of abdominal distension, which was later presumed to be due to disseminated tuberculosis (TB) after excluding the possible differentials. During the treatment course, she was going through repeated attacks of hypovolemic shock and hypoglycemia due to adrenocortical insufficiency. This, along with the history of prolonged amenorrhea 4 years back due to severe postpartum hemorrhage in her last pregnancy, has led us to our diagnosis of partial Sheehan's syndrome. After 1 month of starting steroid and anti-TB therapy, it was quite surprising when she presented with features of pancytopenia and antitubercular drug-induced hepatitis. Discussion Sheehan's syndrome may have a varying degree of presentation depending upon the degree of damage to the pituitary gland, which includes amenorrhea, lactation failure, adrenocortical insufficiency, hyponatremia, hypoglycemia, as well as pancytopenia in some rare instances The hormone panel especially the thyroid profile should be monitored carefully. Such cases are often challenging to deal with because of their varying degrees of presentation and the delay in diagnosis due to a lack of clinical suspicion. Conclusion Therefore, we believe that this rare presentation of pancytopenia in Sheehan's syndrome with fluctuating thyroid profile and abdominal TB in the background will let clinicians approach such a rare disease differently.
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Gradinaru E, Furculescu C, Trandafir A, Opris-Belinski D, Saulescu IC. Myopathic syndrome revealing a rare condition: Sheehan syndrome, a case-based review. Clin Rheumatol 2023; 42:1705-1712. [PMID: 36757535 DOI: 10.1007/s10067-023-06535-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
This report presents a case of a Sheehan syndrome diagnosed with a delay of 29 years after occurrence of first symptoms, following a laborious birth ended with dead fetus and massive hemorrhage. The 50-year-old patient, with early menopause from the age of 21, is referred to our rheumatology department to investigate the etiology of a myopathic syndrome, which started 2 months before and gradually worsened. The differential diagnosis took into consideration the autoimmune, infectious, paraneoplastic, endocrinological, and drug-induced myopathic syndrome. Paraclinical investigations revealed panhypopituitarism, and cerebral magnetic resonance imaging detected empty-sella. The etiology of a myopathic syndrome is often multifactorial; therefore, it is important to continue the investigations even after identifying one possible etiological factor, especially when it does not seem to fully explain the clinical-paraclinical picture. Usually, the multiple dimensions of panhypopituitarism bring the patient to various medical specialties depending on the dominant symptomatology. Given the rarity of the above-mentioned syndrome in the present, and the long gap between the initial event and the final diagnosis, its identification continues to be a challenge.
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Affiliation(s)
- Elena Gradinaru
- Department of Internal Medicine and Rheumatology, Sfanta Maria" Hospital, 011172, Bucharest, Romania
| | - Catalin Furculescu
- Department of Internal Medicine and Rheumatology, Sfanta Maria" Hospital, 011172, Bucharest, Romania
| | - Andreea Trandafir
- Department of Internal Medicine and Rheumatology, Sfanta Maria" Hospital, 011172, Bucharest, Romania.,Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474, Bucharest, Romania
| | - Daniela Opris-Belinski
- Department of Internal Medicine and Rheumatology, Sfanta Maria" Hospital, 011172, Bucharest, Romania.,Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474, Bucharest, Romania
| | - Ioana Cristina Saulescu
- Department of Internal Medicine and Rheumatology, Sfanta Maria" Hospital, 011172, Bucharest, Romania. .,Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474, Bucharest, Romania.
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Yu M, Sun L, Yang HL, Sun H, Wang C, Yao S, Yang P. A rare endocrine cause of ventricular tachycardia: a case series of two patients and a literature review. Cardiovasc J Afr 2022; 33:277-281. [PMID: 36162825 PMCID: PMC9887437 DOI: 10.5830/cvja-2022-043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 08/15/2022] [Indexed: 10/08/2023] Open
Abstract
Sheehan's syndrome is a type of hypopituitarism caused by massive uterine bleeding and hypovolaemic shock after or during delivery. Heart involvement has been documented sporadically among the various clinical manifestations of Sheehan's syndrome but life-threatening arrhythmias are infrequent. Here, we report on two rare cases of ventricular tachycardia caused by Sheehan's syndrome. Both female patients were diagnosed with Sheehan's syndrome 30 years previously, due to massive postpartum bleeding. Both of them terminated hormone replacement therapy recently. Both patients presented with torsade de pointes. The electrocardiogram showed prolonged QT interval. In addition to potassium supplementation and anti-arrhythmia therapy, steroids and thyroid hormone replacement therapy were employed, QT-interval prolongation and T-wave inversion were normalised, and implantable cardioverter defibrillator implantation was avoided. One of the patients was recovering well at the one-year follow up and the other patient was in a coma at the time of this report. We also review the literature for cases of Sheehan's syndrome presenting with ventricular tachycardia.
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Affiliation(s)
- Ming Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Lin Sun
- Department of Endocrinology, The First Hospital of Jilin University, Changchun, China
| | - Hong-Liang Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Huan Sun
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Chang Wang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China
| | - Shuai Yao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, China.
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Mandal S, Mukhopadhyay P, Banerjee M, Ghosh S. Clinical, Endocrine, Metabolic Profile, and Bone Health in Sheehan's Syndrome. Indian J Endocrinol Metab 2020; 24:338-342. [PMID: 33088757 PMCID: PMC7540820 DOI: 10.4103/ijem.ijem_345_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/04/2020] [Accepted: 07/11/2020] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Soumita Mandal
- Department of Endocrinology, R. G. Kar Medical College, Kolkata, West Bengal, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Mainak Banerjee
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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Shinde SD, Sabnis GR, Lanjewar CP, Kerkar PG. A rare endocrine cause of electrical storm - a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2017; 1:ytx008. [PMID: 31020067 PMCID: PMC6176984 DOI: 10.1093/ehjcr/ytx008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/18/2017] [Accepted: 10/04/2017] [Indexed: 11/30/2022]
Abstract
Sheehan’s syndrome, also called Simmond’s syndrome, postpartum apoplexy, postpartum pituitary necrosis, and postpartum panhypopituitary syndrome, is the name given to postpartum hypopituitarism. The syndrome is caused by an infarction in the adenohypophysis, usually precipitated by massive uterine haemorrhage and hypovolemic shock during or after childbirth. Extensive destruction of pituitary cells results in varying degree of hypopituitarism. Acute loss of adenohypophysis function can be fatal without glucocorticoid and thyroid replacement therapy and survivors will require life time hormonal replacement therapy. Most cases present in the postpartum period with lactation failure or after months to years after the delivery. In many affected women, anterior pituitary dysfunction is not diagnosed for many years. Dyselectrolytemia is one of a common presentation in Sheehan’s syndrome. Herein, we report a case of a 35-year old female with a history of obstetric hysterectomy 2 years ago in view of severe postpartum haemorrhage with history of failure of lactation and three episodes of syncope since last 1½ years and now presented with polymorphic ventricular tachycardia which required DC cardioversion. She was referred as a case of long QT syndrome. On investigating further, she had hypokalaemia secondary to hypopituitarism due to Sheehan’s syndrome.
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Affiliation(s)
- Sunny D Shinde
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Girish R Sabnis
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Charan P Lanjewar
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Prafulla G Kerkar
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
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Abstract
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.
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Affiliation(s)
- Züleyha Karaca
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Bashir A Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
| | - Hatice S Dokmetas
- Department of Endocrinology, Istanbul Medipol University Medical School, Istanbul, Turkey
| | - Hulusi Atmaca
- Department of Endocrinology, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
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