Sheehan's syndrome differential diagnosis: Difference between revisions

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Revision as of 20:47, 24 August 2017

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	Physical examination	Laboratory findings	Gold standard	Imaging	Other investigation findings
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 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	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(40%) GH excess	The most accurate test is a pituitary biopsy which will show lymphocytic infiltration.	CT & MRI typically reveal --features of a pituitary mass Diffuse and homogeneous contrast enhancement	Assays for anti-TPO and anti-Tg Ab
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 hyperdense lesion. MRI is done in cases of inconclusive CT.	Blood tests may be done to check: PT/INR and aPTT Pituitary hormonal assay
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	Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)
Simmond's disease/Pituitary cachexia	Chronic	+/-	+	Oligo/amenorrhea	Cachexia Premature aging	Progressive emaciation 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	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	Assays for anti-TPO and anti-Tg Ab FNA biopsy
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	Genetic tests (karyotype) Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations
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 Features of hypothyroidism and hypoadrenalism	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 Anti-adrenal Ab testing
Menopause	Chronic	-	+/-	Oligo/amenorrhea	Hot flashes Insomnia Weight gain and bloating Mood changes	Vaginal atrophy Loss of pelvic muscle tone	↑ FSH ↓ Estradiol and inhibin	FSH > LH

References

↑ Rolih CA, Ober KP (1993). "Pituitary apoplexy". Endocrinol. Metab. Clin. North Am. 22 (2): 291–302. PMID 8325288.
↑ 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.
↑ 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.
↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.

Template:WH Template:WS

[pmid8325288-1] Rolih CA, Ober KP (1993). "Pituitary apoplexy". Endocrinol. Metab. Clin. North Am. 22 (2): 291–302. PMID 8325288.

[pmid1520058-2] 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.

[pmid8183446-3] 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.

[pmid9541295-4] Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

[pmid7758238-5] 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.

[pmid26262437-6] 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.

[pmid7629223-7] 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.

[pmid8345854-8] 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.

[pmid21668725-9] 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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@@ Line 8: / Line 8: @@
 ==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>
 {| class="wikitable"
@@ Line 59: / Line 58: @@
 |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
-* [[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]]
@@ Line 90: / Line 63: @@
 |<nowiki>+/-</nowiki>
 |<nowiki>+</nowiki>
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * Associated with [[autoimmune]] conditions
@@ Line 116: / Line 89: @@
 |[[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]]
@@ Line 144: / Line 119: @@
 |<nowiki>-</nowiki>
 |<nowiki>+</nowiki>
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * [[Erectile dysfunction]]
@@ Line 157: / Line 132: @@
 * [[Nipple discharge|Nipple]] discharge
 |Decreased levels of  pituitary hormones in blood.
-|MRI
+|[[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|Simmond's disease]]/[[Pituitary]] [[cachexia]]
 |Chronic
 |<nowiki>+/-</nowiki>
 | +
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * [[Cachexia]]
@@ Line 175: / Line 150: @@
 * Loss of body hair
 |Decreased levels of anterior pituitary hormones in blood.
-|MRI
+|[[Magnetic resonance imaging|MRI]]
 |
 |Pituitary hormone stimulation tests
 ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
 |-
-|Primary hypothyroidism
+|[[Primary hypothyroidism]]
 |Chronic
 |<nowiki>+/-</nowiki>
 |<nowiki>-</nowiki>
-|Oligomenorrhea/[[menorrhagia]]
+|[[Oligomenorrhea]]/[[menorrhagia]]
 |
 * Cold intolerance
@@ Line 204: / Line 179: @@
 * Rest of pituitary hormone levels WNL
-|TSH levels
+|[[TSH]] levels
 |Done to rule out ant pituitary cause
 |
@@ Line 210: / Line 185: @@
 *FNA biopsy
 |-
-|Primary hypogonadotropic hypogonadism
+|Primary [[Hypogonadotropic hypogonadism]]
 |Chronic
 |<nowiki>-</nowiki>
 |<nowiki>-</nowiki>
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * [[Hot flushes]]
@@ Line 251: / Line 226: @@
 * [[Thyrotropin]] and free [[thyroxine]]
 |-
-|Panhypopituitarism
+|[[Panhypopituitarism]]
 |Chronic
 |<nowiki>-</nowiki>
 |<nowiki>+</nowiki>
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * [[Polyuria]]
@@ Line 268: / Line 243: @@
 * [[Papilledema]]
 |All pituitary hormones decreased
-|MRI
+|[[Magnetic resonance imaging|MRI]]
 |
 |Left hand and wrist [[radiograph]] for [[bone age]]
 |-
-|Primary adrenal insufficiency/Addison's disease
+|[[Primary adrenal insufficiency]]/[[Addison's disease]]
 |Chronic
 |<nowiki>-</nowiki>
@@ Line 292: / Line 267: @@
 * [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
-|CT abdomen
+|[[Computed tomography|CT]] [[abdomen]]
 |CT abdomen
 |
@@ Line 301: / Line 276: @@
 * Anti-adrenal [[Antibody|Ab]] testing
 |-
-|Menopause
+|[[Menopause]]
 |Chronic
 |<nowiki>-</nowiki>
 |<nowiki>+/-</nowiki>
-|Oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
 * [[Hot flashes]]

Sheehan's syndrome differential diagnosis: Difference between revisions

Revision as of 20:47, 24 August 2017

Overview

Differentiating Sheehan's Syndrome from other Diseases

References

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