Sheehan's syndrome differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Sheehan's syndrome}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Sheehan%27s_syndrome]]
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{IQ}}  


==Overview==
==Overview==
*[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
Sheehan's syndrome must be differentiated from other diseases causing [[hypopituitarism]], such as [[lymphocytic hypophysitis]], [[pituitary apoplexy]], [[hypothyroidism]], [[Addison's disease]], [[panhypopituitarism]], [[empty sella syndrome]], [[hypogonadotropic hypogonadism]], [[Simmonds' disease]], hypoprolactinemia, and [[menopause]].
*[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Differentiating Sheehan's Syndrome from other Diseases==
==Differentiating Sheehan's Syndrome from other Diseases==
Sheehan syndrome must be differentiated from lymphocytic hypophysitis, pituitary apoplexy<ref name="pmid8325288">{{cite journal |vauthors=Rolih CA, Ober KP |title=Pituitary apoplexy |journal=Endocrinol. Metab. Clin. North Am. |volume=22 |issue=2 |pages=291–302 |year=1993 |pmid=8325288 |doi= |url=}}</ref><ref name="pmid1520058">{{cite journal |vauthors=Vidal E, Cevallos R, Vidal J, Ravon R, Moreau JJ, Rogues AM, Loustaud V, Liozon F |title=Twelve cases of pituitary apoplexy |journal=Arch. Intern. Med. |volume=152 |issue=9 |pages=1893–9 |year=1992 |pmid=1520058 |doi= |url=}}</ref><ref name="pmid8183446">{{cite journal |vauthors=Lazaro CM, Guo WY, Sami M, Hindmarsh T, Ericson K, Hulting AL, Wersäll J |title=Haemorrhagic pituitary tumours |journal=Neuroradiology |volume=36 |issue=2 |pages=111–4 |year=1994 |pmid=8183446 |doi= |url=}}</ref>, and SAH.
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><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>
<small>
{| class="wikitable"
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Onset}}
! colspan="5" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Manifestations}}
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diagnosis}}
|-
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|History and Symptoms}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Physical examination}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Laboratory findings}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Gold standard}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Imaging}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Other investigation findings}}
|-
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Trumatic delivery}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Lactation failure}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Menstrual irregularities}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}}
|-
![[Sheehan's syndrome]]
|Acute
|<nowiki>++</nowiki>
| ++
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|Symptoms of:
* [[Adrenal insufficiency]]
 
* [[Hypothyroidism]]
|
* [[Breast tissue]] [[atrophy]]
 
* Decreased [[axillary]] and [[pubic]] hair growth
|
* [[Pancytopenia]]
 
* [[Eosinophilia]]
 
* [[Hyponatremia]]
 
* Low [[fasting plasma glucose]]


* Decreased levels of [[anterior pituitary]] [[hormones]] in blood


===Differentiating Sheehan's syndrome on the basis of ===
|
{|
* Clinical diagnosis 
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
 
! rowspan="2" |Diseases
* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
!History and Symptoms
|CT/MRI:  
!Physical Examination
* Sequential changes of pituitary enlargement followed by:  
!Laboratory Findings
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
! rowspan="2" |Other Findings
|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
!
! rowspan="8" |Physical Finding 1
!
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Sheehan's Syndrome
![[Lymphocytic hypophysitis]]
| rowspan="7" style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
|Acute
| rowspan="7" style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+/-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* Associated with [[autoimmune]] conditions
 
* Generalized [[headache]]
 
* Retro-orbital or Bitemporal [[pain]]
 
* Mass lesion effect such as [[Visual field defect|visual field defects]]
|
* [[Diabetes insipidus|DI]]
 
* [[Autoimmune]] [[thyroiditis]]
|
* Decreased pituitary hormones([[Gonadotropins]] most common)
 
* [[Hyperprolactinemia]](40%)
 
* [[Growth hormone|GH]] excess
|
* [[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]]
|
* [[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]
 
* Diffuse and homogeneous contrast enhancement
|[[Assay|Assays]] for:
* Anti-TPO Ab
* Anti-Tg Ab
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pituitary apoplexy]]
![[Pituitary apoplexy]]
| style="background: #F5F5F5; padding: 5px;" |
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>++</nowiki>
|[[Oligomenorrhea|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.
|
* [[Magnetic resonance imaging|MRI]]
|
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion
 
* [[MRI]]: If inconclusive [[CT]]
|
[[Blood tests]] may be done to check:
* [[PT]]/[[INR]] and [[aPTT]]
 
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lymphocytic hypophysitis]]
![[Empty sella syndrome]]
| style="background: #F5F5F5; padding: 5px;" |
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Erectile dysfunction]]
 
* [[Headache]]
 
* Low [[libido]]
 
|
* Signs of raised [[intracranial pressure]] may be present
 
* [[Nipple discharge|Nipple]] discharge
|
* Decreased levels of  pituitary hormones in blood.
|
* [[MRI]]
|
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
|
* [[Pituitary]] hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Empty sella syndrome]]
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
| style="background: #F5F5F5; padding: 5px;" |
|Chronic
|<nowiki>+/-</nowiki>
| +
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Cachexia]]
* [[Premature aging|Premature]] aging
|
* Progressive [[emaciation]]
 
* Loss of body hair
|
* Decreased levels of [[anterior pituitary]] hormones in blood.
|
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any [[pituitary]] cause
|
* [[Pituitary]] hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Hypothyroidism
! [[Primary hypothyroidism|Hypothyroidism]]
| style="background: #F5F5F5; padding: 5px;" |
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|[[Oligomenorrhea]]/[[menorrhagia]]
|
* Cold intolerance
* [[Constipation]]
|
* Dry skin
 
* [[Bradycardia]]
 
* Hair loss
 
* [[Myxedema]]
 
* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
|
* Low [[T3]],[[T4]]
 
* Normal/low [[Thyroid-stimulating hormone|TSH]]
 
* Rest of [[pituitary]] hormone levels NL
|
* [[TSH]] levels
|
* Done to rule out any [[pituitary]] cause
|
*Assays for anti-TPO Ab and anti-Tg Ab
*FNA biopsy
|-
|-
|Hypogonadotropic Hypogonadism
![[Hypogonadotropic hypogonadism]]
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Hot flushes]]
 
* Energy and mood changes
 
* Decreased [[libido]]
|
* [[Breast tissue]] [[atrophy]]
* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
|
* Low [[estrogen]], [[testosterone]]
 
* High [[FSH]]/[[Luteinizing hormone|LH]]
|
* [[FSH]]
* [[Luteinizing hormone|LH]]
|
* Done to rule out any [[pituitary]] cause
|
|
* Genetic tests  ([[karyotype]])
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
|-
|-
|Hypoprolactinemia
!Hypoprolactinemia
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* [[Infertility]]
* Subfertiliy
|
* Puerperal agalactogenesis
|
* No workup is necessary
|
* Decreased [[prolactin]] levels
|
* Done to rule out any [[pituitary]] cause
|
|
|}
* [[Prolactin]] assay in [[3rd trimester]]
 
* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]]


===Use if the above table can not be made===
* [[Thyrotropin]] and free [[thyroxine]]
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 1
![[Panhypopituitarism]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Chronic
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" |
|<nowiki>+</nowiki>
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Polyuria]]
 
* [[Polydipsia]]
* Features of [[hypothyroidism]] and [[hypoadrenalism]]
|
* [[Growth failure]]
 
* B/L [[hemianopsia]]
 
* [[Papilledema]]
|
* All [[pituitary]] hormones decreased
|
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any pituitary cause
|
* Left hand and wrist [[radiograph]] for [[bone age]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
![[Primary adrenal insufficiency]]/[[Addison's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Chronic
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" |
| -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|<nowiki>-</nowiki>
|
* [[Hypoglycemia]]
 
* [[Hypotension]]
|
* [[Dehydration]]
 
* [[Hyperpigmentation]]
 
* loss of [[pubic]] and [[axillary]] hair
 
|
* [[Hyponatremia]] with/without [[hyperkalemia]]
 
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|
* Abdominal [[Computed tomography|CT]]
|
* Abdominal [[Computed tomography|CT]]
|
* Serum [[cortisol]] testing
 
* Serum [[ACTH]] testing
 
* Anti-adrenal [[Antibody|Ab]] testing
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
![[Menopause]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Chronic
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" |
|<nowiki>+/-</nowiki>
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|-
|
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
* [[Hot flashes]]  
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Insomnia]]
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* [[Weight gain]] and [[bloating]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* Mood changes
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|
|-
* [[Vaginal atrophy]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
* Loss of pelvic [[muscle tone]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* ↑ [[FSH]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* ↓ [[Estradiol]] and [[inhibin]]
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|
* [[FSH]] > [[LH]]
|
* Normal
|
* [[Endometrial biopsy]]
|}
|}
</small>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
​
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
[[Category:Emergency medicine]]
[[Category:Obstetrics]]

Latest revision as of 00:09, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Sheehan's syndrome must be differentiated from other diseases causing hypopituitarism, such as lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, panhypopituitarism, empty sella syndrome, hypogonadotropic hypogonadism, Simmonds' disease, hypoprolactinemia, and menopause.

Differentiating Sheehan's Syndrome from other Diseases

Sheehan's syndrome should be differentiated from other diseases causing hypopituitarism.[1][2][3][4][5][6][7]

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
Sheehan's syndrome Acute ++ ++ Oligo/amenorrhea Symptoms of:
  • Clinical diagnosis
  • Most senitive test: Low baseline prolactin levels w/o response to TRH
 CT/MRI:
  • Sequential changes of pituitary enlargement followed by:
  • Shrinkage and necrosis leading to decreased sellar volume or empty sella
Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Retro-orbital or Bitemporal pain
  • Diffuse and homogeneous contrast enhancement
 Assays for:
  • Anti-TPO Ab
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache
  • CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Decreased levels of pituitary hormones in blood.
Simmonds' disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Loss of body hair
Hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Dry skin
  • Hair loss
  • Assays for anti-TPO Ab and anti-Tg Ab
  • FNA biopsy
Hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Energy and mood changes
Hypoprolactinemia Chronic - + -
  • Puerperal agalactogenesis
  • No workup is necessary
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • Done to rule out any pituitary cause
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea
  • Normal

References

  1. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.

​ Template:WH Template:WS

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