PANHYPOPITUITARISM DUE TO SHEEHAN’S SYNDROME IN A PATIENT WITH RECURRENT HYPONATREMIA: CASE REPORT FROM NEPAL

Introduction: Panhypopituitarism, deficiency of all pituitary hormones (anterior pituitary hormones: adrenocorticotropic hormone, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, prolactin, growth hormone; posterior pituitary hormones: oxytocin, vasopressin). Sheehan’s syndrome also known as postpartum hypopituitarism is one of the causes of panhypopituitarism, which is characterized by hypopituitarism due to necrosis of pituitary gland secondary to massive postpartum hemorrhage. In this case, a 50 years female presented with the history of vomiting and loss of appetite since 2 years with severe hyponatremia, and decreased pituitary hormones levels in laboratory findings with significant obstetric history is diagnosed with Sheehan’s Syndrome.


INTRODUCTION
Panhypopituitarism is the deficiency of all pituitary hormones that can have variable presentation based on the hormones involved, and Sheehan's syndrome is one of the causes of panhypopituitarism. 1 Sheehan's syndrome is due to the necrosis of pituitary gland, caused by the massive postpartum hemorrhage leading to impaired blood supply to the gland.Symptoms usually become evident years after delivery, but in rare cases develop acutely. 2 Diagnosis of Sheehan's syndrome can be made based on the following criteria:history of severe postpartum hemorrhage, severe hypotension or shock that needs blood transfusion or fluid replacement, failure of postpartum lactation, no menstruation after the delivery, hypopituitarism that can be partial or complete and radio-imaging (Computed Tomography Scan or Magnetic Resonance Imaging) finding of empty sella. 3tient with Sheehan's syndrome presents with variable symptoms of panhypopituitarism, vomiting, loss of appetite, generalized weakness with hyponatremia due to adrenal insufficiency 4 , hypothyroidism or hypovolemia and anemia.Hyponatremia may be acute (<48 hours duration), or chronic (>48 hours duration); mild (130-134 mEq/L), moderate (120-129 mEq/L) or severe (<120 mEq/L). 5In our case patient (Fig. 1) presented with the episodes of hyponatremia since 2 years.• Vomiting for 2 years

CASE SUMMARY
• Loss of appetite for 2 years Blood count showed: Normochromic, normocytic anemia (10.0 gm%)   Patient was treated with Sodium-Chloride 3% via infusion pump.Alter sensorium (GCS) improved with correction of sodium.Vomiting subsided with anti-emetic (ondansetron) drug.After the patient improved, detailed clinical history and clinical examination was performed.Clinical examination showed no abnormalities in any of the system.Mild pallor was present.Cardiovascular, respiratory, nervous system findings were within normal limit.Urinary sodium investigation was sent as a part of hyponatremia work up, which was high.There was a history of severe postpartum hemorrhage with history of blood transfusion two pint whole blood at the time of delivery of her fourth child 11 years back.Delayed presentation of Sheehan's syndrome was suspected and pituitary hormones immunoassay was performed, that showed panhypopituitarism.Patient was treated with Tablet Hydrocortisone10mg (1 tab at 8:00 am and ½ tab at 4:00 pm.Tablet Levothyroxine was started at 50 mcg daily (1 hour before breakfast).Patient health status was improved and patient was hemodynamically stable.Patient was discharged on oral hydrocortisone and oral levothyroxine and is planned for DEXA scan for bone mass density and initiation of growth hormone therapy in follow up.One month follow up showed no complaints regarding symptoms, hyponatremia, or hormonal therapy.Follow up blood count report showed hemoglobin level 13.0 gm% with normal sodium level (137 mEq/L).Generalized weakness, loss of appetite was improved.

DISCUSSION
Sheehan's syndrome is usually evident years after delivery 2 with variable nonspecific symptoms of hypopituitarism.When there is the necrosis of pituitary gland, there is the progressive deficiency of pituitary hormones.In this case, patient with history of massive postpartum hemorrhage during her last child birth went undiagnosed for 2 years with the recurrence of symptoms even after the supportive management.Patient developed recurrent hyponatremia, anemia (

CONSENT
An informed and written consent was obtained from the mother for publication.

Table 1 : Complete blood count report Blood Count Values Normal Range Remarks
years,treated for electrolyte imbalance (Sodium ranging from: 114-121mEq/L), took medications, after which the symptoms used to subsided for a weeks to months but used to recur.In last one month, the frequency of vomiting has progressed to such an extent that she used to have vomiting after taking each feeds.There is a history of loss of appetite since 2 years, since the progression of vomiting with the history of generalized body weakness.Patient has developed alter sensorium since last 1 day, not recognizing family members and irrelevant talks.On General Examination: Patient was ill looking, not oriented to time, place and person.GCS: E4V3M6, Pallor: present.Vitals: Pulse rate: 79 beats/minute, regular, normal in volume and character, no radio-radial and radio-femoral delay.All peripheral pulses are palpable.Blood Pressure: 100/60 mm of Hg, right arm, supine position.Temperature: 98.2 F, right axillary Respiratory rate: 18 breaths/minute, regular, thoracoabdominal Spo2-97% in Room Air; GRBS: 106 mg/dl Lab investigations in emergency department are as follows:Platelet count 155,000 cells/Cumm 150,000-400,000

Table 2 : Urine Routine and Microscopy Examination
ECG: Sinus Rhythm, Chest X-ray: Normal findings.

Table .
Fig. 3) due to pituitary necrosis assisted in diagnosis in this patient with such clinical background.Proper counseling about medications use improved the patient compliance of taking medications timely, improving the overall patient outcome.CONCLUSIONThe diagnosis of Sheehan's syndrome can be delayed due to non-specific and variable symptoms.Appropriate clinical history (including detailed obstetric history), examination, laboratories and radio-imaging investigations help in diagnosis.Initiation of corticosteroids medications, thyroid hormone replacement therapy with other supportive medications improves the patient's symptoms with good outcomes.