Sheehan's syndrome differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Sheehan's syndrome}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Sheehan%27s_syndrome]]
{{CMG}}; {{AE}} {{IQ}}  
{{CMG}}; {{AE}} {{IQ}}  


==Overview==
==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.<ref name="pmid8325288">{{cite journal |vauthors=Rolih CA, Ober KP |title=Pituitary apoplexy |journal=Endocrinol. Metab. Clin. North Am. |volume=22 |issue=2 |pages=291–302 |year=1993 |pmid=8325288 |doi= |url=}}</ref><ref name="pmid1520058">{{cite journal |vauthors=Vidal E, Cevallos R, Vidal J, Ravon R, Moreau JJ, Rogues AM, Loustaud V, Liozon F |title=Twelve cases of pituitary apoplexy |journal=Arch. Intern. Med. |volume=152 |issue=9 |pages=1893–9 |year=1992 |pmid=1520058 |doi= |url=}}</ref><ref name="pmid8183446">{{cite journal |vauthors=Lazaro CM, Guo WY, Sami M, Hindmarsh T, Ericson K, Hulting AL, Wersäll J |title=Haemorrhagic pituitary tumours |journal=Neuroradiology |volume=36 |issue=2 |pages=111–4 |year=1994 |pmid=8183446 |doi= |url=}}</ref>
Sheehan's syndrome must be differentiated from other diseases causing [[hypopituitarism]], such as [[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==
==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><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>
 
<small>
{| class="wikitable"
{| class="wikitable"
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
Line 27: Line 27:
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}}
|-
|-
|Sheehan's syndrome
![[Sheehan's syndrome]]
|Acute
|Acute
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
| ++
| ++
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|Symptoms of:
* Adrenal insufficiency symptoms
* [[Adrenal insufficiency]]


* Hypothyroidism features
* [[Hypothyroidism]]
|
|
* Breast tissue atrophy
* [[Breast tissue]] [[atrophy]]


* Decreased axillary and pubic hair growth
* Decreased [[axillary]] and [[pubic]] hair growth
|
|
* Pancytopenia
* [[Pancytopenia]]
 
* Eosinophilia
 
* Hyponatremia
 
* Low fasting plasma glucose


* Decreased levels of anterior pituitary hormones in blood.
* [[Eosinophilia]]


|
* [[Hyponatremia]]
* Dx is clinical 


* Most senitive test is low baseline prolactin levels w/o response to TRH.
* Low [[fasting plasma glucose]]
|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
|<nowiki>+/-</nowiki>
|<nowiki>++</nowiki>
|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


|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 hyper-dense lesion.
* Clinical diagnosis 


* [[MRI]] is done in cases of inconclusive [[CT]].
* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
|CT/MRI:
* Sequential changes of pituitary enlargement followed by:
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
|
|
[[Blood tests]] may be done to check:
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
* [[PT]]/[[INR]] and [[aPTT]]
 
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
|[[Lymphocytic hypophysitis]]
![[Lymphocytic hypophysitis]]
|Acute
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Associated with autoimmune conditions
* Associated with [[autoimmune]] conditions


* Generalized [[headache]]
* Generalized [[headache]]
Line 98: Line 75:
* Mass lesion effect such as [[Visual field defect|visual field defects]]
* Mass lesion effect such as [[Visual field defect|visual field defects]]
|
|
* DI
* [[Diabetes insipidus|DI]]


* Autoimmune thyroiditis
* [[Autoimmune]] [[thyroiditis]]
|
|
* Decreased pituitary hormones(Gonadotropins most common)
* Decreased pituitary hormones([[Gonadotropins]] most common)


* Hyperprolactinemia(40%)
* [[Hyperprolactinemia]](40%)


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


* Diffuse and homogeneous contrast enhancement
* Diffuse and homogeneous contrast enhancement
|Assays for anti-TPO and anti-Tg Ab
|[[Assay|Assays]] for:
* Anti-TPO Ab
* 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


|Xanthochromia
|[[Digital subtraction angiography]]
|
|
* Noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* Decreased levels of [[anterior pituitary]] hormones in blood.
* [[Computed tomography|CT]] shows hyperattenuating material filling the [[subarachnoid space]].
|
|
[[Lumbar puncture|Lumbar puncture (LP)]]  shows:
* [[Magnetic resonance imaging|MRI]]
* Elevated opening [[pressure]]
|
* Elevated [[Red blood cell|red blood cell (RBC)]]
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion
* [[Xanthochromic|Xanthochromia]]
 
* [[MRI]]: If inconclusive [[CT]]
|
[[Blood tests]] may be done to check:
* [[PT]]/[[INR]] and [[aPTT]]
 
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
|[[Empty sella syndrome]]
![[Empty sella syndrome]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Erectile dysfunction
* [[Erectile dysfunction]]


* Headache
* [[Headache]]


* Low libido
* Low [[libido]]


|
|
* Signs of raised intracranial pressure may be present
* Signs of raised [[intracranial pressure]] may be present


* Nipple discharge
* [[Nipple discharge|Nipple]] discharge
|Decreased levels of  pituitary hormones in blood.
|
|MRI
* Decreased levels of  pituitary hormones in blood.
|Empty sella containing CSF  
|
|Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
* [[MRI]]
|
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
|
* [[Pituitary]] hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
|Simmond's disease/Pituitary chachexia
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
| +
| +
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Cachexia
* [[Cachexia]]
 
* [[Premature aging|Premature]] aging
* Premature aging
|
|
* Progressive emaciation
* Progressive [[emaciation]]


* Loss of body hair
* Loss of body hair
|Decreased levels of anterior pituitary hormones in blood.
|MRI
|
|
|Pituitary hormone stimulation tests(Metoclopramide and clomiphene citrate stimulation tests)
* Decreased levels of [[anterior pituitary]] hormones in blood.
|
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any [[pituitary]] cause
|
* [[Pituitary]] hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
|Primary hypothyroidism
! [[Primary hypothyroidism|Hypothyroidism]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Oligomenorrhea/menorrhagia
|[[Oligomenorrhea]]/[[menorrhagia]]
|
|
* Cold intolerance
* Cold intolerance
* Constipation
* [[Constipation]]
|
|
* Dry skin
* Dry skin


* Bradycardia
* [[Bradycardia]]


* Hair loss
* Hair loss


* Myxedema
* [[Myxedema]]


* Delayed relaxation phase of deep tendon reflexes
* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
|
|
* Low T3,T4
* Low [[T3]],[[T4]]


* High TSH
* Normal/low [[Thyroid-stimulating hormone|TSH]]


* Rest of pituitary hormone levels WNL
* Rest of [[pituitary]] hormone levels NL
|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 Ab and anti-Tg Ab
*FNA biopsy
*FNA biopsy
|-
|-
|Primary hypogonadotropic hypogonadism
![[Hypogonadotropic hypogonadism]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Oligo/amenorrhea
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Hot flushes
* [[Hot flushes]]


* Energy and mood changes
* Energy and mood changes


* Decreased libido
* Decreased [[libido]]
|
|
* [[Breast tissue]] [[atrophy]]
* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
|
|
* Low estrogen, testosterone
* Low [[estrogen]], [[testosterone]]


* High FSH/LH
* High [[FSH]]/[[Luteinizing hormone|LH]]
|
|
* [[FSH]]
* [[Luteinizing hormone|LH]]
|
|
* Done to rule out any pituitary cause
* Done to rule out any [[pituitary]] cause
|
|
* Genetic tests  (karyotype)
* Genetic tests  ([[karyotype]])
* Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
|-
|-
|Hypoprolactinemia
!Hypoprolactinemia
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Infertility
Subfertiliy
|Puerperal agalactogenesis
|No workup is necessary
|
|
|Done to rule out any pituitary cause
* [[Infertility]]
* Subfertiliy
|
* Puerperal agalactogenesis
|
* No workup is necessary
|
* Decreased [[prolactin]] levels
|
* Done to rule out any [[pituitary]] cause
|
|
* Prolactin assay in 3rd trimester
* [[Prolactin]] assay in [[3rd trimester]]


* LH, FSH
* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]]


* 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]]


* Polydipsia
* [[Polydipsia]]
* Features of hypothyroidism and hypoadrenalism
* Features of [[hypothyroidism]] and [[hypoadrenalism]]
|
|
* Growth failure
* [[Growth failure]]


* B/L hemianopsia
* B/L [[hemianopsia]]


* Papilledema
* [[Papilledema]]
|All pituitary hormones decreased
|
|MRI
* All [[pituitary]] hormones decreased
|
|
|Left hand and wrist radiograph for bone age
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any pituitary cause
|
* 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 276: Line 281:
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
|
* Hypoglycemia
* [[Hypoglycemia]]


* Hypotension
* [[Hypotension]]
|
|
* Dehydration
* [[Dehydration]]


* Hyperpigmentation
* [[Hyperpigmentation]]


* loss of pubic and axillary hair
* loss of [[pubic]] and [[axillary]] hair


|
|
* Hyponatremia with/without hyperkalemia
* [[Hyponatremia]] with/without [[hyperkalemia]]


* Plasma renin activity to aldosterone ratio
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|CT abdomen
|
|CT abdomen
* Abdominal [[Computed tomography|CT]]
|
|
* Serum cortisol testing
* Abdominal [[Computed tomography|CT]]
|
* Serum [[cortisol]] testing


* Serum ACTH testing
* Serum [[ACTH]] testing


* Anti-adrenal 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]]
* Insomnia
* [[Insomnia]]
* Weight gain and bloating
* [[Weight gain]] and [[bloating]]
* Mood changes
* Mood changes
|
|
* Vaginal atrophy
* [[Vaginal atrophy]]
* Loss of pelvic muscle tone
* Loss of pelvic [[muscle tone]]
|
|
* ↑ FSH
* ↑ [[FSH]]
* ↓ Estradiol and inhibin
* ↓ [[Estradiol]] and [[inhibin]]
|FSH > LH
|
|
* [[FSH]] > [[LH]]
|
|
* Normal
|
* [[Endometrial biopsy]]
|}
|}
</small>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
​
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
[[Category:Emergency medicine]]
[[Category:Obstetrics]]

Latest revision as of 00:09, 30 July 2020

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 other diseases causing hypopituitarism, such as 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 Symptoms of:
  • Clinical diagnosis
  • 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 Ab
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache
  • 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.
Simmonds' disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Loss of body hair
Hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Dry skin
  • Hair loss
  • Assays for anti-TPO Ab and anti-Tg Ab
  • FNA biopsy
Hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Energy and mood changes
Hypoprolactinemia Chronic - + -
  • Puerperal agalactogenesis
  • No workup is necessary
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • Done to rule out any pituitary cause
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea
  • Normal

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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