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 and menopause.<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><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>
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 31: Line 32:
| ++
| ++
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|Symptoms of:
* [[Adrenal insufficiency]] symptoms
* [[Adrenal insufficiency]]  


* [[Hypothyroidism]] features
* [[Hypothyroidism]]  
|
|
* [[Breast tissue]] [[atrophy]]
* [[Breast tissue]] [[atrophy]]
Line 51: Line 52:


|
|
* Dx is clinical  
* Clinical diagnosis  


* 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 83: 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 Ab
* anti-Tg Ab
* Anti-Tg Ab
|-
|-
![[Pituitary apoplexy]]
![[Pituitary apoplexy]]
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* [[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 134: 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|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
Line 152: 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]]
|
* 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>
Line 179: Line 189:
* Low [[T3]],[[T4]]
* Low [[T3]],[[T4]]


* High [[Thyroid-stimulating hormone|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
|
|
*Assays for anti-TPO and anti-Tg Ab
* [[TSH]] levels
|
* Done to rule out any [[pituitary]] cause
|
*Assays for anti-TPO Ab and anti-Tg Ab
*FNA biopsy
*FNA biopsy
|-
|-
!Primary [[Hypogonadotropic hypogonadism]]
![[Hypogonadotropic hypogonadism]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
Line 200: Line 212:
* 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]])
Line 218: Line 235:
* [[Infertility]]
* [[Infertility]]
* Subfertiliy
* Subfertiliy
|Puerperal agalactogenesis
|No workup is necessary
|
|
|Done to rule out any pituitary cause
* 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]]
Line 245: Line 266:


* [[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]]
|
* 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]]
Line 270: Line 295:


* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|[[Computed tomography|CT]] [[abdomen]]
|
|CT abdomen
* Abdominal [[Computed tomography|CT]]
|
* Abdominal [[Computed tomography|CT]]
|
|
* Serum [[cortisol]] testing
* Serum [[cortisol]] testing
Line 295: Line 322:
* ↑ [[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.

​ Template:WH Template:WS

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