Sheehan's syndrome differential diagnosis: Difference between revisions

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|-
|-
|[[Pituitary apoplexy]]
|[[Pituitary apoplexy]]
|
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
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|-
|-
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]]
|
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
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|-
|-
|[[Subarachnoid hemorrhage]]
|[[Subarachnoid hemorrhage]]
|
|Acute
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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|-
|-
|Simmond's disease/Pituitary chachexia
|Simmond's disease/Pituitary chachexia
|
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
| +
| +
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|
|
|-
|-
|Primary Hypothyroidism
|Primary hypothyroidism
|
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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*
*
|-
|-
|Primary Hypogonadotropic hypogonadism
|Primary hypogonadotropic hypogonadism
|
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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|-
|-
|Hypoprolactinemia
|Hypoprolactinemia
|
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
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|-
|-
|Panhypopituitarism
|Panhypopituitarism
|
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
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|Left hand and wrist radiograph for bone age
|Left hand and wrist radiograph for bone age
|-
|-
|Primary adrenal insufficiency
|Primary adrenal insufficiency/Addison's disease
|
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| -
| -
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|-
|-
|Menopause
|Menopause
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|Chronic
|
|
|
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|Female athlete triad
|Female athlete triad
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|Chronic
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===Differentiating Sheehan's syndrome on the basis of ===
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |Diseases
! rowspan="2" |Course
! rowspan="2" |History and Symptoms
! rowspan="2" |Physical Examination
! rowspan="2" |Laboratory Findings
! rowspan="2" |Other Findings
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!
! rowspan="9" |Physical Finding 1
!
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Sheehan's Syndrome
| rowspan="4" |Acute
| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pituitary apoplexy]]
|
|
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lymphocytic hypophysitis]]
|
|
| style="background: #F5F5F5; padding: 5px;" |
|-
|SAH
|
|
|
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Empty sella syndrome]]
| rowspan="4" |Chronic
|
|
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Primary Hypothyroidism
|
|
| style="background: #F5F5F5; padding: 5px;" |
|-
|Hypogonadotropic Hypogonadism
|
|
|
|-
|Hypoprolactinemia
|
|
|
|}
 
===Use if the above table can not be made===
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 1
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|}
 
==References==
{{Reflist|2}}
{{Reflist|2}}


{{WH}}
{{WH}}
{{WS}}
{{WS}}

Revision as of 19:29, 22 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Sheehan syndrome must be differentiated from lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, panhypopititarism, empty sella syndrome, hypogonadotropic hypogonadism, Simmond's disease, hypoprolactinemia, menopause,female athlete triadand SAH.[1][2][3]

Differentiating Sheehan's Syndrome from other Diseases

Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.[4][5][6][7][8][9]

Diseases Onset Manifestations Diagnosis
History and Symptoms Physical examination Laboratory findings Gold standard Imaging Other investigation findings
Trumatic delivery Lactation failure Menstrual irregularities Other features
Sheehan's syndrome Acute ++ ++ oligo/amenorrhea
  • Adrenal insufficiency symptoms
  • Hypothyroidism features
 -Breast tissue atrophy

-decreased axillary and pubic hair growth

Pancytopenia

Eosinophilia

Hyponatremia

Low fasting plasma glucose

Decreased levels of anterior pituitary hormones in blood.

Dx is clinical with key feature of traumatic delivery.

-Most senitive test is low baseline prolactin levels w/o response to TRH.

Sequential changes of pituitary enlargement followed by shrinkage and necrosis leading to decreased sellar volume or empty sella.
Pituitary apoplexy Acute +/- ++ oligo/amenoorhea Severe headache -Visual acuity defects

-CN palsies (nerves III, IV, V, and VI)

Decreased levels of anterior pituitary hormones in blood. MRI
  • MRI is done in cases of inconclusive CT. An MRI is more sensitive in identifying intrasellarmass and soft tissue changes

Blood tests may be done to check:

Lymphocytic hypophysitis Acute +/- + oligo/amenoorhea -Associated with autoimmune conditions
  • Retro-orbital or Bitemporal pain
 -DI

-Autoimmune thyroiditis

-Decreased pituitary hormones(Gonadotropins most common)

-Hyperprolactinemia

-GH excess

Pituitary biopsy CT & MRI typically reveal --features of a pituitary mass

-diffuse and homogeneous contrast enhancement

The most accurate test is a pituitarybiopsy which will show lymphocyticinfiltration.
Subarachnoid hemorrhage Acute - - - -Signs of meningeal irritation Xanthochromia Digital subtraction angiography

Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show:

Empty sella syndrome Chronic - + oligo/aenorrhea -Erectile dysfunction

-Headache

-Low libido

-Nipple discharge

Signs of raised intracranial pressure may be present Decreased levels of pituitary hormones in blood. MRI Empty sella containing CSF
Simmond's disease/Pituitary chachexia Chronic +/- + oligo/aenorrhea -Cachexia

-Premature aging

-Progressive emaciation

-Loss of body hair

Decreased levels of anterior pituitary hormones in blood.
Primary hypothyroidism Chronic +/- - oligomenorrhea

or menorrhagia

  • Cold intolerance
  • Constipation
 Dry skin

Bradycardia

Hair loss

Myxedema

Delayed relaxation phase of deep tendon reflexe

low T3,T4

High TSH

Rest of pituitary hormone levels WNL

TSH levels Done to rule out ant pituitary cause
Primary hypogonadotropic hypogonadism Chronic - - oligo/aenorrhea Hot flushes

Energy and mood changes

Decreased libido

Low estrogen, testosterone

High FSH/LH

  • Done to rule out any pituitary cause
  • Blood tests for anemia and iron
  • Genetic tests including a karyotype to check chromosomal structure
  • Prolactin level (milk hormone)
  • Sperm count
  • Thyroid tests
Hypoprolactinemia Chronic - + - Infertility

Subfertiliy

Puerperal agalactogenesis No workup is necessary Done to rule out any pituitary cause -Prolactin assay in 3rd trimester

-LH, FSH

-Thyrotropin and free thyroxine

Panhypopituitarism Chronic - + oligo/aenorrhea Polyuria

Polydipsia

-Growth failure

-B/L hemianopsia

-Papilledema

all pituitary hormones decreased MRI Left hand and wrist radiograph for bone age
Primary adrenal insufficiency/Addison's disease Chronic - - - Hypoglycemia

Hypotension

-Dehydration

-Hyperpigmentation

-loss of pubic and axillary hair

-Hyponatremia with/without hyperkalemia

-Plasma renin activity to aldosterone ratio

CT abdomen CT abdomen -Serum cortisol testing

-Serum ACTH testing

-Antiadrenal Ab testing

Menopause Chronic
Female athlete triad Chronic
  1. ↑ Rolih CA, Ober KP (1993). "Pituitary apoplexy". Endocrinol. Metab. Clin. North Am. 22 (2): 291–302. PMID 8325288.
  2. ↑ Vidal E, Cevallos R, Vidal J, Ravon R, Moreau JJ, Rogues AM, Loustaud V, Liozon F (1992). "Twelve cases of pituitary apoplexy". Arch. Intern. Med. 152 (9): 1893–9. PMID 1520058.
  3. ↑ Lazaro CM, Guo WY, Sami M, Hindmarsh T, Ericson K, Hulting AL, Wersäll J (1994). "Haemorrhagic pituitary tumours". Neuroradiology. 36 (2): 111–4. PMID 8183446.
  4. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  5. ↑ Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH (1995). "Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature". Clin. Endocrinol. (Oxf). 42 (3): 315–22. PMID 7758238.
  6. ↑ Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S (2015). "Diagnosis of Primary Hypophysitis in Germany". J. Clin. Endocrinol. Metab. 100 (10): 3841–9. doi:10.1210/jc.2015-2152. PMID 26262437.
  7. ↑ Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S (1995). "Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings". J. Clin. Endocrinol. Metab. 80 (8): 2302–11. doi:10.1210/jcem.80.8.7629223. PMID 7629223.
  8. ↑ Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H (1993). "Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus". N. Engl. J. Med. 329 (10): 683–9. doi:10.1056/NEJM199309023291002. PMID 8345854.
  9. ↑ Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS (2011). "Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman". Emerg Med Australas. 23 (3): 372–5. doi:10.1111/j.1742-6723.2011.01425.x. PMID 21668725.

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