Sheehan's syndrome differential diagnosis

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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.

Differentiating Sheehan's Syndrome from other Diseases

Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.

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/amenorrhea	Severe headache Nausea and vomiting Paralysis of eye muscles (diplopia) Changes in vision	Visual acuity defects CN palsies (nerves III, IV, V , and VI)	Decreased levels of anterior pituitary hormones in blood.	MRI	CT scan without contrast is the initial test of choice. Pituitary hemorrhage on CT presents as a hyper-dense lesion. 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: PT/INR and aPTT Pituitary hormonal assay
Lymphocytic hypophysitis	Acute	+/-	+	Oligo/amenorrhea	Associated with autoimmune conditions Generalized headache Retro-orbital or Bitemporal pain Mass lesion effect such as visual field defects	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	-	-	-	Thunderclap headache( worst headache of life) Double vision Nausea and vomiting Symptoms of meningeal irritation	Signs of meningeal irritation	Xanthochromia	Digital subtraction angiography	The modality of choice for diagnosis of subarachnoid hemorrhage is noncontrast head computed tomography (CT), with or without lumbar puncture.[1] CT shows hyperattenuating material filling the subarachnoid space.	Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show: Elevated opening pressure Elevated red blood cell (RBC) Xanthochromia
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
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.
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
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	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/amenorrhea	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	-	+/-	Oligo/amenorrhea
Female athlete triad	Chronic	-	-	Oligo/amenorrhea