Sheehan's syndrome differential diagnosis: Difference between revisions

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* Most senitive test: low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
* Most senitive test: low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
|CT/MRI:  
|CT/MRI:  
* sequential changes of pituitary enlargement followed by  
* Sequential changes of pituitary enlargement followed by  
* shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
|Pituitary hormone stimulation tests
|
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Lymphocytic hypophysitis]]
![[Lymphocytic hypophysitis]]
Line 84: Line 84:


* [[Growth hormone|GH]] excess
* [[Growth hormone|GH]] excess
|[[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]]
|
|
* [[CT]] & [[MRI]]: features of a [[Pituitary gland|pituitary]] [[mass]]
* [[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]]
|
* [[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]


* Diffuse and homogeneous contrast enhancement
* Diffuse and homogeneous contrast enhancement
|[[Assay|Assays]] for:
|[[Assay|Assays]] for:
* anti-TPO   
* Anti-TPO   
* anti-Tg Ab
* Anti-Tg Ab
|-
|-
![[Pituitary apoplexy]]
![[Pituitary apoplexy]]
Line 107: Line 108:
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)


|Decreased levels of [[anterior]] pituitary hormones in blood.
|[[Magnetic resonance imaging|MRI]]
|
|
* [[CT]] scan without [[Contrast medium|contrast]]:hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion
* Decreased levels of [[anterior]] pituitary hormones in blood.
|
* [[Magnetic resonance imaging|MRI]]
|
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion


* [[MRI]]: if inconclusive [[CT]]  
* [[MRI]]: If inconclusive [[CT]]  
|
|
[[Blood tests]] may be done to check:
[[Blood tests]] may be done to check:
Line 135: Line 138:


* [[Nipple discharge|Nipple]] discharge
* [[Nipple discharge|Nipple]] discharge
|Decreased levels of  pituitary hormones in blood.
|
|[[MRI]]
* Decreased levels of  pituitary hormones in blood.
|[[Empty sella]] containing [[Cerebrospinal fluid|CSF]]  
|
|Pituitary hormone stimulation tests
* [[MRI]]
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Simmond's Disease|Simmond's disease]]/[[Pituitary]] [[cachexia]]
![[Simmond's Disease|Simmond's disease]]/[[Pituitary]] [[cachexia]]
Line 153: Line 159:


* Loss of body hair
* Loss of body hair
|Decreased levels of anterior pituitary hormones in blood.
|[[Magnetic resonance imaging|MRI]]
|
|
|Pituitary hormone stimulation tests
* Decreased levels of anterior pituitary hormones in blood.
([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|
* [[Magnetic resonance imaging|MRI]]
|
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Primary hypothyroidism]]
![[Primary hypothyroidism]]
Line 183: Line 191:


* Rest of pituitary hormone levels WNL
* Rest of pituitary hormone levels WNL
|[[TSH]] levels
|
|Done to rule out ant pituitary cause
* [[TSH]] levels
|
* Done to rule out any pituitary cause
|
|
*Assays for anti-TPO and anti-Tg Ab
*Assays for anti-TPO and anti-Tg Ab
Line 206: Line 216:
* High [[FSH]]/[[LH]]
* High [[FSH]]/[[LH]]
|
|
|Done to rule out any pituitary cause
|
* Done to rule out any pituitary cause
|
|
* Genetic tests  ([[karyotype]])
* Genetic tests  ([[karyotype]])
Line 219: Line 230:
* [[Infertility]]
* [[Infertility]]
* Subfertiliy
* Subfertiliy
|Puerperal agalactogenesis
|No workup is necessary
|
|
|Done to rule out any pituitary cause
* Puerperal agalactogenesis
|
* No workup is necessary
|
|
* Done to rule out any pituitary cause
|
|
* [[Prolactin]] assay in [[3rd trimester]]
* [[Prolactin]] assay in [[3rd trimester]]
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* [[Papilledema]]
* [[Papilledema]]
|All pituitary hormones decreased
|[[Magnetic resonance imaging|MRI]]
|
|
|Left hand and wrist [[radiograph]] for [[bone age]]
* All pituitary hormones decreased
|
* [[Magnetic resonance imaging|MRI]]
|
|
* Left hand and wrist [[radiograph]] for [[bone age]]
|-
|-
![[Primary adrenal insufficiency]]/[[Addison's disease]]
![[Primary adrenal insufficiency]]/[[Addison's disease]]
Line 271: Line 288:


* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|Abdominal [[Computed tomography|CT]]
|
|Abdominal [[Computed tomography|CT]]  
* Abdominal [[Computed tomography|CT]]
|
* Abdominal [[Computed tomography|CT]]
|
|
* Serum [[cortisol]] testing
* Serum [[cortisol]] testing
Line 296: Line 315:
* ↑ [[FSH]]
* ↑ [[FSH]]
* ↓ [[Estradiol]] and [[inhibin]]
* ↓ [[Estradiol]] and [[inhibin]]
|[[FSH]] > [[LH]]
|
* [[FSH]] > [[LH]]
|
|
|
|
|}
|}
</small>




Revision as of 15:42, 1 September 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's syndrome must be differentiated from lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, panhypopituitarism, empty sella syndrome, hypogonadotropic hypogonadism, Simmonds' disease, hypoprolactinemia, and menopause.

Differentiating Sheehan's Syndrome from other Diseases

Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.[1][2][3][4][5][6][7]

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: low baseline prolactin levels w/o response to TRH
 CT/MRI:
  • Sequential changes of pituitary enlargement followed by
  • Shrinkage and necrosis leading to decreased sellar volume or empty sella
Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Retro-orbital or Bitemporal pain
  • Diffuse and homogeneous contrast enhancement
 Assays for:
  • Anti-TPO
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache
  • Decreased levels of anterior pituitary hormones in blood.
  • CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Decreased levels of pituitary hormones in blood.
Simmond's disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Loss of body hair
  • Decreased levels of anterior pituitary hormones in blood.
Primary hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Dry skin
  • Hair loss
  • Rest of pituitary hormone levels WNL
  • Done to rule out any 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 - + -
  • Puerperal agalactogenesis
  • No workup is necessary
  • Done to rule out any pituitary cause
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • All pituitary hormones decreased
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea


References

  1. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.

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