Sheehan's syndrome differential diagnosis: Difference between revisions

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	Physical examination	Laboratory findings	Gold standard	Imaging	Other investigation findings
Sheehan's syndrome	Acute	++	++	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	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	Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)
Lymphocytic hypophysitis	Acute	+/-	+	Oligo/amenorrhea	Associated with autoimmune conditions Generalized headache Retro-orbital or Bitemporal pain Mass lesion effect such as visual field defects	DI Autoimmune thyroiditis	Decreased pituitary hormones(Gonadotropins most common) Hyperprolactinemia(40%) GH excess	Pituitary biopsy: lymphocytic infiltration	CT & MRI: Features of a pituitary mass Diffuse and homogeneous contrast enhancement	Assays for: Anti-TPO Ab Anti-Tg Ab
Pituitary apoplexy	Acute	+/-	++	Oligo/amenorrhea	Severe headache Nausea and vomiting Paralysis of eye muscles (diplopia) Changes in vision	Visual acuity defects CN palsies (nerves III, IV, V , and VI)	Decreased levels of anterior pituitary hormones in blood.	MRI	CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion MRI: If inconclusive CT	Blood tests may be done to check: PT/INR and aPTT Pituitary hormonal assay
Empty sella syndrome	Chronic	-	+	Oligo/amenorrhea	Erectile dysfunction Headache Low libido	Signs of raised intracranial pressure may be present Nipple discharge	Decreased levels of pituitary hormones in blood.	MRI	Empty sella containing CSF	Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)
Simmonds' disease/Pituitary cachexia	Chronic	+/-	+	Oligo/amenorrhea	Cachexia Premature aging	Progressive emaciation Loss of body hair	Decreased levels of anterior pituitary hormones in blood.	MRI	Done to rule out any pituitary cause	Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)
Hypothyroidism	Chronic	+/-	-	Oligomenorrhea/menorrhagia	Cold intolerance Constipation	Dry skin Bradycardia Hair loss Myxedema Delayed relaxation phase of deep tendon reflexes	Low T3,T4 Normal/low 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	Chronic	-	-	Oligo/amenorrhea	Hot flushes Energy and mood changes Decreased libido	Breast tissue atrophy Decreased maturation of vaginal mucosa	Low estrogen, testosterone High FSH/LH	FSH LH	Done to rule out any pituitary cause	Genetic tests (karyotype) Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations
Hypoprolactinemia	Chronic	-	+	-	Infertility Subfertiliy	Puerperal agalactogenesis	No workup is necessary	Decreased prolactin levels	Done to rule out any pituitary cause	Prolactin assay in 3rd trimester LH, FSH Thyrotropin and free thyroxine
Panhypopituitarism	Chronic	-	+	Oligo/amenorrhea	Polyuria Polydipsia Features of hypothyroidism and hypoadrenalism	Growth failure B/L hemianopsia Papilledema	All pituitary hormones decreased	MRI	Done to rule out any pituitary cause	Left hand and wrist radiograph for bone age
Primary adrenal insufficiency/Addison's disease	Chronic	-	-	-	Hypoglycemia Hypotension	Dehydration Hyperpigmentation loss of pubic and axillary hair	Hyponatremia with/without hyperkalemia Plasma renin activity to aldosterone ratio	Abdominal CT	Abdominal CT	Serum cortisol testing Serum ACTH testing Anti-adrenal Ab testing
Menopause	Chronic	-	+/-	Oligo/amenorrhea	Hot flashes Insomnia Weight gain and bloating Mood changes	Vaginal atrophy Loss of pelvic muscle tone	↑ FSH ↓ Estradiol and inhibin	FSH > LH	Normal	Endometrial biopsy

References

↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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

[pmid9541295-1] Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

[pmid7758238-2] 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.

[pmid26262437-3] 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.

[pmid7629223-4] 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.

[pmid8345854-5] 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.

[pmid21668725-6] 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.

[pmid9747750-7] 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.

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@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Sheehan's syndrome}}
+[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Sheehan%27s_syndrome]]
 {{CMG}}; {{AE}} {{IQ}}
 ==Overview==
-Sheehan syndrome must be differentiated from lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism and SAH.<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>
+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.<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>
+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" |Diseases
+! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
-! rowspan="3" |Onset
+! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Onset}}
-! colspan="5" |Manifestations
+! colspan="5" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Manifestations}}
-! colspan="4" |Diagnosis
+! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diagnosis}}
 |-
-! colspan="4" |History and Symptoms
+! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|History and Symptoms}}
-! rowspan="2" |Physical examination
+! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Physical examination}}
-! rowspan="2" |Laboratory findings
+! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Laboratory findings}}
-! rowspan="2" |Gold standard
+! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Gold standard}}
-! rowspan="2" |Imaging
+! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Imaging}}
-! rowspan="2" |Other investigation findings
+! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Other investigation findings}}
 |-
-!Trumatic delivery
+! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Trumatic delivery}}
-!Lactation failure
+! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Lactation failure}}
-!Menstrual irregularities
+! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Menstrual irregularities}}
-!Other features
+! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}}
 |-
-|Sheehan's syndrome
+![[Sheehan's syndrome]]
 |Acute
 |<nowiki>++</nowiki>
 | ++
-|oligo/amenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
+|Symptoms of:
+* [[Adrenal insufficiency]]
+* [[Hypothyroidism]]
 |
-* Adrenal insufficiency symptoms
+* [[Breast tissue]] [[atrophy]]
-* Hypothyroidism features
+* Decreased [[axillary]] and [[pubic]] hair growth
-|<nowiki>-Breast tissue atrophy</nowiki>
+|
+* [[Pancytopenia]]
--decreased axillary and pubic hair growth
+* [[Eosinophilia]]
-|Pancytopenia
-Eosinophilia
+* [[Hyponatremia]]
-Hyponatremia
+* Low [[fasting plasma glucose]]
-Low fasting plasma glucose
+* Decreased levels of [[anterior pituitary]] [[hormones]] in blood
-Decreased levels of anterior pituitary hormones in blood.
+|
+* Clinical diagnosis
-|Dx is clinical  with key feature of traumatic delivery.
+* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
--Most senitive test is 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.
+* Sequential changes of pituitary enlargement followed by:
+* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
 |
+* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
 |-
-|[[Pituitary apoplexy]]
+![[Lymphocytic hypophysitis]]
+|Acute
+|<nowiki>+/-</nowiki>
+|<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
+|-
+![[Pituitary apoplexy]]
+|Acute
 |<nowiki>+/-</nowiki>
 |<nowiki>++</nowiki>
-|oligo/amenoorhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |Severe [[headache]]
 * [[Nausea and vomiting]]
 * Paralysis of eye muscles ([[diplopia]])
 * Changes in vision
-|<nowiki>-Visual acuity defects</nowiki>
+|
+* [[Visual acuity]] defects
--CN palsies (nerves III, IV, V, and VI)
+* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
-|Decreased levels of anterior pituitary hormones in blood.
-|MRI
 |
-* [[CT]] scan without [[Contrast medium|contrast]] is the initial test of choice. [[Pituitary hemorrhage|Pituitary hemorrhag]]<nowiki/>e on [[CT]] presents as a hyper-dense lesion.
+* 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]] is done in cases of inconclusive [[CT]]. An [[MRI]] is more sensitive in identifying [[intrasellar]]<nowiki/>mass and soft tissue changes
+* [[MRI]]: If inconclusive [[CT]]
 |
 [[Blood tests]] may be done to check:
@@ Line 78: / Line 122: @@
 * [[Pituitary gland|Pituitary]] [[hormonal]] assay
 |-
-|[[Lymphocytic hypophysitis]]
+![[Empty sella syndrome]]
+|Chronic
+|<nowiki>-</nowiki>
+|<nowiki>+</nowiki>
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
 |
-|<nowiki>+/-</nowiki>
+* [[Erectile dysfunction]]
-|<nowiki>+</nowiki>
-|oligo/amenoorhea
-|<nowiki>-Associated with autoimmune conditions</nowiki>
-* Generalized [[headache]]
-* Retro-orbital or Bitemporal [[pain]]
+* [[Headache]]
-* Most often seen in late [[pregnancy]] or the [[postpartum]] period
+* Low [[libido]]
-* Mass lesion effect such as [[Visual field defect|visual field defects]]
+|
-* [[Hypopituitarism]]
+* Signs of raised [[intracranial pressure]] may be present
-|<nowiki>-DI</nowiki>
--Autoimmune thyroiditis
-|<nowiki>-Decreased pituitary hormones(Gonadotropins most common)</nowiki>
--Hyperprolactinemia
+* [[Nipple discharge|Nipple]] discharge
--GH excess
-|Pituitary biopsy
-|[[CT]] & [[MRI]] typically reveal --features of a [[Pituitary gland|pituitary]] [[mass]]
--diffuse and homogeneous contrast enhancement
-|The most accurate test is a [[Pituitary gland|pituitary]][[biopsy]] which will show [[lymphocytic]][[Infiltration (medical)|infiltration]].
-|-
-|[[Subarachnoid hemorrhage]]
 |
-|<nowiki>-</nowiki>
+* Decreased levels of  pituitary hormones in blood.
-|<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
 |
-* [[Headache|Severe headache]]
+* [[MRI]]
-* [[Thunderclap headache|Thunderclap]]
-* Described as the worst [[headache]] of life
-* [[Double vision]]
-* [[Nausea]] and [[vomiting]]
-* Symptoms of [[meningeal irritation]]
-* Sudden [[Loss of consciousness|decreased level of consciousness]]
-|<nowiki>-Signs of meningeal irritation</nowiki>
-|Xanthochromia
-|[[Digital subtraction angiography]]
 |
-* The [[modality]] of choice for [[diagnosis]] of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
+* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
-* [[Computed tomography|CT]] shows hyperattenuating material filling the [[subarachnoid space]].
 |
-[[Lumbar puncture|Lumbar puncture (LP)]] is necessary when there is a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
+* [[Pituitary]] hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
-* Elevated opening [[pressure]]
-* Elevated [[Red blood cell|red blood cell (RBC)]]
-* [[Xanthochromic|Xanthochromia]]
 |-
-|[[Empty sella syndrome]]
+![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
 |Chronic
-|<nowiki>-</nowiki>
+|<nowiki>+/-</nowiki>
-|<nowiki>+</nowiki>
+| +
-|oligo/aenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
-|<nowiki>-Erectile dysfunction</nowiki>
--Headache
--Low libido
--Nipple discharge
-|Signs of raised intracranial pressure may be present
-|Decreased levels of  pituitary hormones in blood.
-|MRI
-|Empty sella containing CSF
 |
-|-
+* [[Cachexia]]
-|Simmond's disease/Pituitary chachexia
+* [[Premature aging|Premature]] aging
 |
-|<nowiki>+/-</nowiki>
+* Progressive [[emaciation]]
-| +
-|oligo/aenorrhea
-|<nowiki>-Cachexia</nowiki>
--Premature aging
+* Loss of body hair
-|<nowiki>-Progressive emaciation</nowiki>
+|
+* Decreased levels of [[anterior pituitary]] hormones in blood.
--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)
 |-
-|Primary Hypothyroidism
+! [[Primary hypothyroidism|Hypothyroidism]]
-|
+|Chronic
 |<nowiki>+/-</nowiki>
 |<nowiki>-</nowiki>
-|oligomenorrhea
+|[[Oligomenorrhea]]/[[menorrhagia]]
-or menorrhagia
 |
-*
 * Cold intolerance
-* Constipation
+* [[Constipation]]
-|Dry skin
+|
+* Dry skin
-Bradycardia
+* [[Bradycardia]]
-Hair loss
+* Hair loss
-Myxedema
+* [[Myxedema]]
-Delayed relaxation phase of deep tendon reflexe
+* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
-|low T3,T4
+|
+* Low [[T3]],[[T4]]
-High TSH
+* Normal/low [[Thyroid-stimulating hormone|TSH]]
-Rest of pituitary hormone levels WNL
+* Rest of [[pituitary]] hormone levels NL
-|TSH levels
+|
-|Done to rule out ant pituitary cause
+* [[TSH]] levels
+|
+* Done to rule out any [[pituitary]] cause
 |
-*
+*Assays for anti-TPO Ab and anti-Tg Ab
+*FNA biopsy
 |-
-|Primary Hypogonadotropic hypogonadism
+![[Hypogonadotropic hypogonadism]]
-|
+|Chronic
 |<nowiki>-</nowiki>
 |<nowiki>-</nowiki>
-|oligo/aenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
-|Hot flushes
+|
+* [[Hot flushes]]
-Energy and mood changes
+* Energy and mood changes
-Decreased libido
+* Decreased [[libido]]
+|
+* [[Breast tissue]] [[atrophy]]
+* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
 |
-|Low estrogen, testosterone
+* Low [[estrogen]], [[testosterone]]
-High FSH/LH
+* High [[FSH]]/[[Luteinizing hormone|LH]]
 |
+* [[FSH]]
+* [[Luteinizing hormone|LH]]
 |
-* Done to rule out any pituitary cause
+* Done to rule out any [[pituitary]] cause
 |
-* Blood tests for anemia and iron
+* Genetic tests  ([[karyotype]])
-* Genetic tests including a karyotype to check chromosomal structure
+* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
-* Prolactin level (milk hormone)
-* Sperm count
-* Thyroid tests
 |-
-|Hypoprolactinemia
+!Hypoprolactinemia
-|
+|Chronic
 |<nowiki>-</nowiki>
 |<nowiki>+</nowiki>
 |<nowiki>-</nowiki>
-|Infertility
-Subfertiliy
-|Puerperal agalactogenesis
-|No workup is necessary
 |
-|Done to rule out any pituitary cause
+* [[Infertility]]
-|<nowiki>-Prolactin assay in 3rd trimester</nowiki>
+* Subfertiliy
+|
+* Puerperal agalactogenesis
+|
+* No workup is necessary
+|
+* Decreased [[prolactin]] levels
+|
+* Done to rule out any [[pituitary]] cause
+|
+* [[Prolactin]] assay in [[3rd trimester]]
--LH, FSH
+* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]]
--Thyrotropin and free thyroxine
+* [[Thyrotropin]] and free [[thyroxine]]
 |-
-|Panhypopituitarism
+![[Panhypopituitarism]]
-|
+|Chronic
 |<nowiki>-</nowiki>
 |<nowiki>+</nowiki>
-|oligo/aenorrhea
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
-|Polyuria
+|
+* [[Polyuria]]
-Polydipsia
+* [[Polydipsia]]
-|<nowiki>-Growth failure</nowiki>
+* Features of [[hypothyroidism]] and [[hypoadrenalism]]
+|
+* [[Growth failure]]
--B/L hemianopsia
+* B/L [[hemianopsia]]
--Papilledema
+* [[Papilledema]]
-|all pituitary hormones decreased
+|
-|MRI
+* All [[pituitary]] hormones decreased
+|
+* [[Magnetic resonance imaging|MRI]]
 |
-|Left hand and wrist radiograph for bone age
+* Done to rule out any pituitary cause
+|
+* Left hand and wrist [[radiograph]] for [[bone age]]
 |-
-|Primary adrenal insufficiency
+![[Primary adrenal insufficiency]]/[[Addison's disease]]
-|
+|Chronic
 |<nowiki>-</nowiki>
 | -
 |<nowiki>-</nowiki>
-|Hypoglycemia
+|
+* [[Hypoglycemia]]
-Hypotension
+* [[Hypotension]]
-|<nowiki>-Dehydration</nowiki>
+|
+* [[Dehydration]]
--Hyperpigmentation
+* [[Hyperpigmentation]]
--loss of pubic and axillary hair
+* loss of [[pubic]] and [[axillary]] hair
-|<nowiki>-Hyponatremia with/without hyperkalemia</nowiki>
+|
+* [[Hyponatremia]] with/without [[hyperkalemia]]
--Plasma renin activity to aldosterone ratio
+* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
-|CT abdomen
-|CT abdomen
-|<nowiki>-Serum cortisol testing</nowiki>
--Serum ACTH testing
--Antiadrenal Ab testing
-|-
-|Menopause
 |
+* Abdominal [[Computed tomography|CT]]
 |
+* Abdominal [[Computed tomography|CT]]
 |
-|
+* Serum [[cortisol]] testing
-|
-|
+* Serum [[ACTH]] testing
-|
-|
-|
-|
-|-
-|Female athlete triad
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|}
-===Differentiating Sheehan's syndrome on the basis of ===
+* Anti-adrenal [[Antibody|Ab]] testing
-{|
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-! rowspan="2" |Diseases
-! rowspan="2" |Course
-! rowspan="2" |History and Symptoms
-! rowspan="2" |Physical Examination
-! rowspan="2" |Laboratory Findings
-! rowspan="2" |Other Findings
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-!
-! rowspan="9" |Physical Finding 1
-!
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Sheehan's Syndrome
+![[Menopause]]
-| rowspan="4" |Acute
+|Chronic
-| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
+|<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px;" |
+|<nowiki>+/-</nowiki>
-| style="background: #F5F5F5; padding: 5px;" |
+|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pituitary apoplexy]]
 |
+* [[Hot flashes]]
+* [[Insomnia]]
+* [[Weight gain]] and [[bloating]]
+* Mood changes
 |
-| style="background: #F5F5F5; padding: 5px;" |
+* [[Vaginal atrophy]]
-|-
+* Loss of pelvic [[muscle tone]]
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lymphocytic hypophysitis]]
 |
+* ↑ [[FSH]]
+* ↓ [[Estradiol]] and [[inhibin]]
 |
-| style="background: #F5F5F5; padding: 5px;" |
+* [[FSH]] > [[LH]]
-|-
-|SAH
-|
-|
-|
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Empty sella syndrome]]
-| rowspan="4" |Chronic
-|
-|
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Primary Hypothyroidism
-|
-|
-| style="background: #F5F5F5; padding: 5px;" |
-|-
-|Hypogonadotropic Hypogonadism
-|
-|
-|
-|-
-|Hypoprolactinemia
-|
 |
+* Normal
 |
+* [[Endometrial biopsy]]
 |}
+</small>
-===Use if the above table can not be made===
-{| 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
-| 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].
-| 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].
-|-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
-| 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].
-| 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].
-|-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
-| 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].
-| 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].
-|-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
-| 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].
-| 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].
-|-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
-| 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].
-| 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].
-|}
 ==References==
 {{Reflist|2}}
 {{WH}}
 {{WS}}
+[[Category:Medicine]]
+[[Category:Endocrinology]]
+[[Category:Up-To-Date]]
+[[Category:Emergency medicine]]
+[[Category:Obstetrics]]

Sheehan's syndrome differential diagnosis: Difference between revisions

Latest revision as of 00:09, 30 July 2020

Overview

Differentiating Sheehan's Syndrome from other Diseases

References

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