Sheehan's syndrome differential diagnosis: Difference between revisions

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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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|Pituitary hormone stimulation tests
|Pituitary hormone stimulation tests
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|[[Pituitary apoplexy]]
|[[Acute]]
|<nowiki>+/-</nowiki>
|<nowiki>++</nowiki>
|Oligo/amenorrhea
|Severe [[headache]]
* [[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
* Changes in vision
|
* [[Visual acuity]] defects
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
|Decreased levels of [[anterior]] pituitary hormones in blood.
|MRI
|
* [[CT]] scan without [[Contrast medium|contrast]] is the initial test of choice. [[Pituitary hemorrhage|Pituitary hemorrhag]]<nowiki/>e on [[CT]] presents as a hyperdense lesion.
* [[MRI]] is done in cases of inconclusive [[CT]].
|
[[Blood tests]] may be done to check:
* [[PT]]/[[INR]] and [[aPTT]]
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]]
Line 90: Line 63:
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Associated with [[autoimmune]] conditions
* Associated with [[autoimmune]] conditions
Line 116: Line 89:
|[[Assay|Assays]] for anti-TPO and anti-Tg Ab
|[[Assay|Assays]] for anti-TPO and anti-Tg Ab
|-
|-
|[[Subarachnoid hemorrhage]]
|[[Pituitary apoplexy]]
|Acute
|[[Acute]]
|<nowiki>-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>++</nowiki>
|<nowiki>-</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|Severe [[headache]]
* [[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
* Changes in vision
|
|
* [[Thunderclap headache|Thunderclap]] [[Headache|headache]]( worst [[headache]] of life)
* [[Visual acuity]] defects


* [[Double vision]]
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
* [[Nausea]] and [[vomiting]]
* Symptoms of [[meningeal irritation]]
|Signs of [[meningeal irritation]]


|[[Xanthochromic|Xanthochromia]]
|Decreased levels of [[anterior]] pituitary hormones in blood.
|[[Digital subtraction angiography]]
|[[Magnetic resonance imaging|MRI]]
|
|
* Noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* [[CT]] scan without [[Contrast medium|contrast]] is the initial test of choice. [[Pituitary hemorrhage|Pituitary hemorrhag]]<nowiki/>e on [[CT]] presents as a hyperdense lesion.
* [[Computed tomography|CT]] shows hyperattenuating material filling the [[subarachnoid space]].
 
* [[MRI]] is done in cases of inconclusive [[CT]].  
|
|
[[Lumbar puncture|Lumbar puncture (LP)]]  shows:
[[Blood tests]] may be done to check:
* Elevated opening [[pressure]]
* [[PT]]/[[INR]] and [[aPTT]]
* Elevated [[Red blood cell|red blood cell (RBC)]]
 
* [[Xanthochromic|Xanthochromia]]
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
|[[Empty sella syndrome]]
|[[Empty sella syndrome]]
Line 144: Line 119:
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* [[Erectile dysfunction]]
* [[Erectile dysfunction]]
Line 157: Line 132:
* [[Nipple discharge|Nipple]] discharge
* [[Nipple discharge|Nipple]] discharge
|Decreased levels of  pituitary hormones in blood.
|Decreased levels of  pituitary hormones in blood.
|MRI
|[[MRI]]
|[[Empty sella]] containing [[Cerebrospinal fluid|CSF]]  
|[[Empty sella]] containing [[Cerebrospinal fluid|CSF]]  
|Pituitary hormone stimulation tests
|Pituitary hormone stimulation tests
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
|Simmond's disease/Pituitary chachexia
|[[Simmond's Disease|Simmond's disease]]/[[Pituitary]] [[cachexia]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
| +
| +
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* [[Cachexia]]
* [[Cachexia]]
Line 175: Line 150:
* Loss of body hair
* Loss of body hair
|Decreased levels of anterior pituitary hormones in blood.
|Decreased levels of anterior pituitary hormones in blood.
|MRI
|[[Magnetic resonance imaging|MRI]]
|
|
|Pituitary hormone stimulation tests
|Pituitary hormone stimulation tests
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
|Primary hypothyroidism
|[[Primary hypothyroidism]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Oligomenorrhea/[[menorrhagia]]
|[[Oligomenorrhea]]/[[menorrhagia]]
|
|
* Cold intolerance
* Cold intolerance
Line 204: Line 179:


* Rest of pituitary hormone levels WNL
* Rest of pituitary hormone levels WNL
|TSH levels
|[[TSH]] levels
|Done to rule out ant pituitary cause
|Done to rule out ant pituitary cause
|
|
Line 210: Line 185:
*FNA biopsy
*FNA biopsy
|-
|-
|Primary hypogonadotropic hypogonadism
|Primary [[Hypogonadotropic hypogonadism]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* [[Hot flushes]]
* [[Hot flushes]]
Line 251: Line 226:
* [[Thyrotropin]] and free [[thyroxine]]
* [[Thyrotropin]] and free [[thyroxine]]
|-
|-
|Panhypopituitarism
|[[Panhypopituitarism]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* [[Polyuria]]
* [[Polyuria]]
Line 268: Line 243:
* [[Papilledema]]
* [[Papilledema]]
|All pituitary hormones decreased
|All pituitary hormones decreased
|MRI
|[[Magnetic resonance imaging|MRI]]
|
|
|Left hand and wrist [[radiograph]] for [[bone age]]
|Left hand and wrist [[radiograph]] for [[bone age]]
|-
|-
|Primary adrenal insufficiency/Addison's disease
|[[Primary adrenal insufficiency]]/[[Addison's disease]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
Line 292: Line 267:


* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|CT abdomen
|[[Computed tomography|CT]] [[abdomen]]
|CT abdomen
|CT abdomen
|
|
Line 301: Line 276:
* Anti-adrenal [[Antibody|Ab]] testing
* Anti-adrenal [[Antibody|Ab]] testing
|-
|-
|Menopause
|[[Menopause]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* [[Hot flashes]]  
* [[Hot flashes]]  

Revision as of 20:47, 24 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
  • 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)

Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Retro-orbital or Bitemporal pain
 The most accurate test is a pituitarybiopsy which will show lymphocyticinfiltration.
  • Diffuse and homogeneous contrast enhancement
 Assays for anti-TPO and anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache Decreased levels of anterior pituitary hormones in blood. MRI
  • MRI is done in cases of inconclusive CT.

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea 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 cachexia Chronic +/- + Oligo/amenorrhea
  • 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
  • Dry skin
  • Hair loss
  • 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
  • Energy and mood changes
 Done to rule out any pituitary cause
Hypoprolactinemia Chronic - + - Infertility

Subfertiliy

Puerperal agalactogenesis No workup is necessary Done to rule out any pituitary cause
Panhypopituitarism Chronic - + Oligo/amenorrhea All pituitary hormones decreased MRI Left hand and wrist radiograph for bone age
Primary adrenal insufficiency/Addison's disease Chronic - - - CT abdomen CT abdomen
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea FSH > LH

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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