Recurrent Life Threatening Hypoglycemia and Hyponatremia- Delayed Presentation of Sheehan’s Syndrome

Abstract

INTRODUCTION: Sheehan’s syndrome refers to post-partum pituitary necrosis due to excessive intra-partum blood loss resulting in panhypopituitarism. Manifestations of Sheehan’s syndrome are a reflection of panhypopituitarism and resulting hormone deficiencies. Although Sheehan’s syndrome can have delayed and variable presentations, both recurrent hypoglycemia and hyponatremia are rare presentations and only few cases are reported in the literature. Present case is a rare presentation of Sheehan’s syndrome with recurrent life threatening hypoglycemia, hyponatremia and addisonian crises 10 years after the last delivery. CASE PRESENTATION: We report a case of a 45-year-old lady who presented to our emergency with gradual asthenia, easy fatiguability since 1 month and altered sensorium due to recurrent hypoglycemia since 2 days. Patient was in shock at presentation and examination revealed features suggestive of hypothyroidism. History revealed loss of menstruation and lactation failure since 10 years after her last delivery. Patient was clinically suspected to be having panhypopituitarism. Biochemical investigations revealed severe hyponatremia, central hypothyroidism and low serum cortisol. Patients MRI brain revealed empty sella thereby confirming the diagnosis of Sheehan’s syndrome. Rapid improvement in patient’s condition was seen following institution of hormone replacement therapy. CONCLUSION: Present case highlights the importance of strongly suspecting the diagnosis of Sheehan’s syndrome in female patients presenting with hypoglycemia, hyponatremia or hypotension irrespective of the time interval from the last delivery, as early treatment can save the patient from life-threatening conditions like hypoglycemia or hyponatremia. Features like central hypothyroidism, lactation failure and loss of menstruation after the last delivery should lead the diagnostic approach towards Sheehan’s syndrome as the possible etiology of hypoglycemia and hyponatremia.