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==Differentiating Sheehan's Syndrome from other Diseases==
==Differentiating Sheehan's Syndrome from other Diseases==
Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=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 |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref>
Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=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 |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref>


{| class="wikitable"
{| class="wikitable"
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* Most senitive test is low baseline prolactin levels w/o response to TRH.
* Most senitive test is low baseline prolactin levels w/o response to TRH.
|CT/MRI shows sequential changes of pituitary enlargement followed by shrinkage and necrosis leading to decreased sellar volume or empty sella.
|CT/MRI shows sequential changes of pituitary enlargement followed by shrinkage and necrosis leading to decreased sellar volume or empty sella.
|
|Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
|-
|-
|[[Pituitary apoplexy]]
|[[Pituitary apoplexy]]
Line 108: Line 107:


* GH excess
* GH excess
|Pituitary biopsy
|The most accurate test is a [[Pituitary gland|pituitary]][[biopsy]] which will show [[lymphocytic]][[Infiltration (medical)|infiltration]].
|
|
* [[CT]] & [[MRI]] typically reveal --features of a [[Pituitary gland|pituitary]] [[mass]]
* [[CT]] & [[MRI]] typically reveal --features of a [[Pituitary gland|pituitary]] [[mass]]


* Diffuse and homogeneous contrast enhancement
* Diffuse and homogeneous contrast enhancement
|The most accurate test is a [[Pituitary gland|pituitary]][[biopsy]] which will show [[lymphocytic]][[Infiltration (medical)|infiltration]].
|Assays for anti-TPO and anti-Tg Ab
|-
|-
|[[Subarachnoid hemorrhage]]
|[[Subarachnoid hemorrhage]]
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|MRI
|MRI
|Empty sella containing CSF  
|Empty sella containing CSF  
|
|Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
|-
|-
|Simmond's disease/Pituitary chachexia
|Simmond's disease/Pituitary chachexia
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|MRI
|MRI
|
|
|
|Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
|-
|-
|Primary hypothyroidism
|Primary hypothyroidism
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|Done to rule out ant pituitary cause
|Done to rule out ant pituitary cause
|
|
*
*Assays for anti-TPO and anti-Tg Ab
*FNA biopsy
|-
|-
|Primary hypogonadotropic hypogonadism
|Primary hypogonadotropic hypogonadism
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* Done to rule out any pituitary cause
* Done to rule out any pituitary cause
|
|
* Blood tests for anemia and iron
* Genetic tests  (karyotype)
* Genetic tests including a karyotype to check chromosomal structure
* Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations
* Prolactin level (milk hormone)
|-
|-
|Hypoprolactinemia
|Hypoprolactinemia
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|Oligo/amenorrhea
|Oligo/amenorrhea
|
|
* Hot flashes
* Insomnia
* Weight gain and bloating
* Mood changes
|
|
* Vaginal atrophy
* Loss of pelvic muscle tone
|
|
|
|
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|
|
|}
|}


==References==
==References==

Revision as of 22:26, 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
  • Most senitive test is low baseline prolactin levels w/o response to TRH.
 CT/MRI shows sequential changes of pituitary enlargement followed by shrinkage and necrosis leading to decreased sellar volume or empty sella. Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea 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.

Blood tests may be done to check:

Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Associated with autoimmune conditions
  • Retro-orbital or Bitemporal pain
  • DI
  • Autoimmune thyroiditis
  • Decreased pituitary hormones(Gonadotropins most common)
  • Hyperprolactinemia(40%)
  • GH excess
 The most accurate test is a pituitarybiopsy which will show lymphocyticinfiltration.
  • Diffuse and homogeneous contrast enhancement
 Assays for anti-TPO and anti-Tg Ab
Subarachnoid hemorrhage Acute - - - Signs of meningeal irritation Xanthochromia Digital subtraction angiography

Lumbar puncture (LP)  shows:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Erectile dysfunction
  • Headache
  • Low libido
  • Signs of raised intracranial pressure may be present
  • Nipple discharge
 Decreased levels of pituitary hormones in blood. MRI Empty sella containing CSF Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
Simmond's disease/Pituitary chachexia Chronic +/- + Oligo/amenorrhea
  • Cachexia
  • Premature aging
  • Progressive emaciation
  • Loss of body hair
 Decreased levels of anterior pituitary hormones in blood. MRI Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
Primary hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Cold intolerance
  • Constipation
  • Dry skin
  • Bradycardia
  • Hair loss
  • Myxedema
  • Delayed relaxation phase of deep tendon reflexes
  • Low T3,T4
  • High TSH
  • Rest of pituitary hormone levels WNL
 TSH levels Done to rule out ant pituitary cause
  • Assays for anti-TPO and anti-Tg Ab
  • FNA biopsy
Primary hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Hot flushes
  • Energy and mood changes
  • Decreased libido
  • Low estrogen, testosterone
  • High FSH/LH
  • Done to rule out any pituitary cause
  • Genetic tests  (karyotype)
  • Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations
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/amenorrhea
  • Polyuria
  • Polydipsia
  • Features of hypothyroidism and hypoadrenalism
  • 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
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea
  • Hot flashes
  • Insomnia
  • Weight gain and bloating
  • Mood changes
  • Vaginal atrophy
  • Loss of pelvic muscle tone
Female athlete triad Chronic - - Oligo/amenorrhea

References

  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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