Case Presentation: A 26-year-old female refugee from Afghanistan with a history of menorrhagia presented after a near syncopal episode and two days of fever, chills, and tooth pain. Per cultural preference, history was obtained from the patient’s husband using interpretive services. He reported that the patient developed cold extremities, fatigue, decreased appetite, weight loss, and repeated hypotensive and hypoglycemic episodes after the birth of her last child three years ago. The patient had no significant family history, except for paternal diabetes. Other localizing symptoms of infection, dizziness, chest pain, shortness of breath, palpitations, acute vaginal blood loss, hematochezia, nausea, gastrointestinal losses, and poor oral intake were denied.The patient was afebrile with a blood pressure of 90/61, heart rate of 101, respiratory rate of 16, and pulse ox 99% on room air, cold, pale skin, capillary refill greater than 3 seconds, global weakness, and dry mucous membranes. Labs revealed a white blood cell count of 6.4 (10*9 cells/L), hemoglobin of 12.9 (g/dL), lactate of 1.2 (mmol/L), negative pregnancy test, thyroid stimulating hormone of 1.3 (mIU/L), potassium of 3.3 (mmol/L), glucose of 69 (mg/dL), sodium of 140 (mmol/L), luteinizing hormone of 8.8 (mIU/L), follicular stimulating hormone of 8.9 (mIU/L), prolactin of 3.3 (ng/mL), and an estradiol of 34 (pg/mL). Thyroid hormone, insulin-like growth factor, and cortisol levels were undetectable. A quantitative adrenal corticotropic hormone level collected at 3pm was 7.5 pg/mL, and an MRI of the pituitary showed an empty sella consistent with Sheehan Syndrome.Hypotension and hypoglycemia resolved with dextrose-infused fluid resuscitation, intravenous levothyroxine and stress-dose intravenous hydrocortisone. Unasyn was used to treat oral infection. The patient was discharged on oral levothyroxine prednisone daily.
Discussion: Sheehan Syndrome is a form of panhypopituitarism secondary to hemorrhagic shock during childbirth resulting in pituitary necrosis from hypoperfusion, causing subsequent panhypopituitarism. Panhypopituitarism etiologies include mass lesions, infarct, hemorrhage, infection, and hypophysitis. The diagnosis of panhypopituitarism is often delayed, as it presents with nonspecific symptoms such as fatigue, cold intolerance, weakness, constipation, hair loss, menstrual abnormalities, and erectile dysfunction. Difficulties obtaining a thorough history due to cultural and linguistic barriers may further contribute to delayed diagnosis. In panhypopituitarism, gonadotropin, prolactin, estrogen, cortisol, growth hormone, thyroid stimulating hormone, and thyroid hormone levels are low and often accompanied by pancytopenia, electrolyte, or glucose derangements. Brain MRI can help identify etiology of the disease, and treatment includes levothyroxine, prednisone, insulin-like growth factor, and sex hormone replacement.
Conclusions: This case also highlights the importance of understanding unique risk factors for panhypopituitarism which disproportionately impact vulnerable patient populations. Panhypopituitarism should be considered in patients with recurrent hypotensive and/or hypoglycemic episodes. In post-partum patients, especially those from developing or third-world countries, Sheehan Syndrome should be considered. Finally, it is important to incorporate background, history, and sociocultural elements into a patient’s overall clinical picture to avoid diagnostic delay.