Fig. 1
(a) Sagittal (red bold arrow) and (b) Coronal T2 weighted (red bold arrow-head) images showing sella filled with CSF and thinned and flattened pituitary (height reduced) lying against floor of sella - partially empty sella. Figure 2: (a) Sagittal T2 weighted (red bold arrow) and (b) Coronal post contrast T1 weighted (red bold arrow-head) images showing reduced pituitary height (2.1mm -as measured between calipers in 2a). Figure 3: (a) Sagittal (red bold arrow) and (b) Coronal T2 weighted (red bold arrow-head) images showing sella filled with CSF and pituitary gland severely thinned, lying flattened against sellar floor.
Table 1
Case descriptions.
| Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | |
|---|---|---|---|---|---|
| Demographics | |||||
| Age (years) | 41 | 34 | 28 | 54 | 53 |
| Weight (Kg) | 65 | 45 | 56 | 47 | 53 |
| Height (cm) | 150 | 148 | 147 | 159 | 144 |
| Co-morbidities | Epilepsy | No | No | No | Systemic hypertension |
| PPH | Yes | Yes | Yes | Yes | Yes |
| Hysterectomy | Yes | Yes | No | No | No |
| Amenorhoea | Yes | Yes | Yes | No | Yes |
| Agalactia | Yes | Yes | Yes | Yes | No |
| Delay in diagnosis post-PPH (years) | 8 | 3 | 2 | 20 | 18 |
| Clinical presentation | |||||
| Encephalopathy | Yes | Yes | Yes | Yes | Yes |
| Hypotension | Yes | Yes | Yes | Yes | No |
| Vasopressors | Yes | Yes | No | No | No |
| Bradycardia | Yes | Yes | Yes | Yes | No |
| LV dysfunction (2D ECHO) | Yes (LVEF 40%) | Yes (LVEF 30%) | No | No | No |
| MV | No | Yes | No | No | No |
| AKI | Yes | No | No | No | No |
| Polyuria | Yes | No | No | No | No |
| Hypoglycemia | Yes | No | Yes | Yes | No |
| Hematological dysfunction | Yes | No | Yes | Yes | No |
| Labs at admission | |||||
| Hb (g/dl) | 7.4 | 10.4 | 9.3 | 8.8 | 12.3 |
| TLC ( /mm3) | 3800 | 5700 | 6100 | 11000 | 4500 |
| Platelets (lacs/ mm3) | 0.75 | 5.1 | 0.75 | 5.5 | 3.5 |
| Urea/Creatinine (mg/dl) | 21/1.0 | 22/0.5 | -/0.7 | 28/0.6 | -/0.5 |
| Na (mEq/L) | 119 | 131 | 113 | 127 | 118 |
| K (mEq/L) | 4.2 | 4.04 | 3.84 | 5.0 | 3.3 |
| T Bil | 0.61 | 0.35 | - | 0.68 | 0.83 |
| D bil | 0.31 | 0.25 | - | 0.30 | 0.39 |
| SGOT/SGPT | 93/47 | 24/10 | /90 | 24/29 | 104/34 |
| ALP | 411 | 219 | - | 112 | 35 |
| Procalcitonin (micg/L) (N: 0-0.05) | 0.11 | 0.73 | - | - | - |
| Pro-BNP (pg/ml) (N: 0-125) | 294 | 7880 | - | - | - |
| USG abdomen | Post-hysterectomy with bilateral adnexal mass with complex septated cystic lesion. | Post-hysterectomy with very minimal pockets of collection. Abdominal drain in position. | Small uterus size | - | Mild left sided pleural effusion |
[i] PPH=Postpartum haemorrhage, MV=Mechanical ventilation, LV dysfunction=Left ventricular dysfunction, LVEF=Left Ventricular Ejection fraction, AKI=Acute Kidney Injury, Polyuria=urine output > 3 Litres/ day, Hypoglycaemia=RBS < 70 mg/dl, 2D ECHO=2 dimensional echocardiography, Hb= Haemoglobin, TLC=Total Leukocyte count, Na=Serum sodium, K=serum potassium, T Bil=Total Bilirubin, D Bil=Direct bilirubin, SGOT/SGPT=Serum glutamate oxaloacetate transaminase/Serum glutamate pyruvate transaminase, ALP=alkaline phosphatase, PRO-BNP=PRO-Brain Natriuretic Peptide, N=normal, - data not available
Table 2
Hormonal profile at admission.
| Hormones | Baseline values | Case 1 | Case 2 | Case 3 | Case 4 | Case 5 |
|---|---|---|---|---|---|---|
| Human GH by CLIA (ng/ml) | Females: 0-8 | - | - | <0.05 | - | - |
| LH (mIU/ml) by CMIA | Normally menstruating females: | 4.9 | 0.01 | 0.29 | - | - |
| Follicular phase: 2.39-6.60 | ||||||
| Mid-cycle peak: 3.06-74.24 | ||||||
| Luteal phase: 0.9-9.33 | ||||||
| Post-menopausal females: 10.39- | ||||||
| 64.57 | ||||||
| FSH (mIU/ml) by CMIA | Normally menstruating females: | 9.92 | 0.06 | 1.25 | 2.2 | 1.01 |
| Follicular phase: 3.03-8.08 | ||||||
| Mid-cycle peak: 2.55-16.69 | ||||||
| Luteal phase: 1.38-5.47 | ||||||
| Post-menopausal females: 26.72- | ||||||
| 133.41 | ||||||
| Estradiol (pg/ml) by CLIA | Normally menstruating females: | - | - | < 10 | - | - |
| Follicular phase: 21-251 | ||||||
| Mid-cycle peak: 38-649 | ||||||
| Luteal phase: 21-312 | ||||||
| Post-menopausal females: | ||||||
| Not on HRT: < 10-28 | ||||||
| On HRT: < 10-144 | ||||||
| ACTH (pg/ml) by CLIA | - | - | - | 15 | - | |
| Morning serum cortisol (micg/dl) by CMIA | 5-23 | 3.3 | 2.2 | 0.1 | 3.69 (15.9 stimulated) | 0.83 (6.36 stimulated) |
| Thyroid profile by CLIA | - | - | ||||
| T3 (ng/ml) | 0.58-1.59 | 0.25 | 0.49 | 0.41 | ||
| Free T4 (ng/dl) | 0.8-1.8 | - | - | 0.17 | 0.67 | - |
| T4 (micg/dl) | 4.87-11.72 | |||||
| TSH (microIU/ml) | 0.35-4.94 | 0.97 | 1.67 | 1.91 | - | 3.17 |
| 1.11 | 4.08 | 0.22 | 1.99 | 3.6 | ||
| Prolactin (ng/ml) by CLIA | Females: | 0.76 | 0.88 | 1.5 | 8.8 | - |
| Non-pregnant: 2.8-29.2 | ||||||
| Pregnancy: 9.7-208.5 | ||||||
| Post-menopausal: 1.8-20.3 |
[i] LH=Luteinizing Hormone, FSH=Follicle Stimulating Hormone, TSH=Thyroid Stimulating Hormone, ACTH=Adrenocorticotropic hormone, GH=Growth Hormone, HRT= Hormone Replacement Therapy, CLIA=Chemi Luminescent Immunoassay, CMIA=ChemiLuminescent Microparticle Immunoassay, - not done, bold hormonal values represent hormonal deficiencies
Table 3
Case reports of Sheehan’s syndrome (SS) from India and other countries.
| Age/PPH/Delay | Clinical presentation | Hormonal profile | Radiology | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Year; Country; Age of patient | PPH | Delay (yrs) | Agalactia | Menstrual problem | Non-specific | Organ failures | Na | GH | PRL | Hypothyroidism | Hypogonadism | Adrenal insufficiency | Pituitary size | Sella volume (ml) | ||||
| TSH | fT3 | fT4 | LH | FSH | ACTH | Cortisol | ||||||||||||
| 2020;16 India 35y/F | yes | 4 | yes | yes | yes | Asthenia, anaemia | ↓ | - | ↓ | ↓ | ↓ | ↓ | ↓/N | ↓ | - | ↓ | ↓ | - |
| 2019;17 India 36y/F | yes | 7 | yes | yes | yes | Myxoedema coma, Coagulopathy, Pancytopenia, Hypoglycaemia | ↓ | - | - | N | ↓ | ↓ | ↓/N | ↓/N | - | ↓ | - | Partially empty sella |
| 2016; 18 India 32y/F | yes | 1 | yes | yes | yes | Anaemia, | - | - | - | ↓ | - | - | - | ↓ | - | ↓ | - | Empty sella |
| 2013; 19 India 41y/F | yes | 22 | yes | yes | yes | Hypoglycaemia Asthenia | ↓ | - | - | - | ↓ | ↓ | - | - | ↓ | ↓ | - | - |
| 2019;3 USA 36y/F | yes | 8 | yes | yes | yes | Chronic pain upper and lower limbs, Hypoglycaemia | ↓ | ↓ | N | ↓ | ↓ | ↓ | ↓ | - | ↓ | CSF in pituitary fossa | Empty sella | |
| 2013;21 Italy 64y/F | - | 30 | - | - | yes | Rhabdomyolysis, hypothyroidism | - | - | - | - | - | - | - | - | ↓ | Atrophy | - | |
| 2013;22 Nepal 38y/F | yes | 5 | - | yes | yes | Sparse hair, Dyspnoea, Bradycardia, Shock | ↓ | ↓ | ↓ | N | ↓ | ↓ | ↓ | - | ↓ | - | Empty sella | |
[i] PPH=Postpartum haemorrhage, Delay = diagnostic delay from PPH to diagnosis of Sheehan’s syndrome, Na=Serum Sodium, GH=Growth hormone, PRL=Prolactin, TSH=Thyroid stimulating hormone, fT3=free Triiodothyronine, T4=levothyroxine, FT4=free levothyroxine LH=Leutenizing hormone, FSH=Follicle stimulating hormone, ACTH=Adrenocorticotrophic hormone, MRI=Magnetic resonance imaging (MRI) brain, N=Normal, =Postpartum haemorrhage, Delay = diagnostic delay from event to presentation, Na=Serum Sodium, GH=Growth hormone, PRL=Prolactin, TSH=Thyroid stimulating hormone, fT3=free Triiodothyronine, T4=levothyroxine, FT4=free levothyroxine LH=Leutenizing hormone, FSH=Follicle stimulating hormone, ACTH=Adrenocorticotrophic hormone, MRI=Magnetic resonance imaging brain, N=Normal, ↓= decrease, mnths=months, d=day,- = data not available