Kidney Week

Abstract: PUB108

Sheehan Syndrome Masquerading as Hyponatremia

Session Information

• Publication Only

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Tahir, Maria, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Maria Tahir, MD

• Siddiqi, Mahwash, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Mahwash Siddiqi, MD

• Raza, Muhammad, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Muhammad Raza, MD

• Trivedi, Naman, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Naman Trivedi, MD, FASN

• Ghahramani, Nasrollah, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Nasrollah Ghahramani, MD, FASN

• Miller, Ronald P., Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States

Ronald P. Miller, MD

Introduction

Sheehan syndrome is an uncommon yet significant cause of hypopituitarism,resulting from ischemic necrosis of pituitary gland after severe postpartum hemorrhage.Diagnosis is often delayed because symptoms are nonspecific and evolve gradually over years.We describe a 42-year-old woman who presented a decade after complicated postpartum hemorrhage with severe hyponatremia and ultimately diagnosed with Sheehan syndrome.

Case Description

She presented with 3-day history of nausea, vomiting and found to have severe hypotonic hyponatremia(serum sodium 116 mmol/L,nadir 113 mmol/L) with elevated urine sodium and osmolality.Initial considerations included hypovolemic hyponatremia due to gastrointestinal losses and syndrome of inappropriate antidiuresis.She was admitted to medical intensive care unit and managed with isotonic saline,hypertonic saline,and oral salt supplementation,with partial correction of sodium levels.
On further evaluation,she reported severe postpartum hemorrhage in 2016 requiring emergency hysterectomy,massive blood transfusion, intensive care admission,vasopressors, and management of disseminated intravascular coagulation with hypovolemic shock.Brain imaging revealed partially empty sella with pituitary atrophy.Endocrine testing revealed low free thyroxine levels and inadequate cortisol response to ACTH stimulation,consistent with central adrenal insufficiency in the setting of hypopituitarism.Following initiation of glucocorticoid therapy, sodium levels improved markedly,supporting adrenal insufficiency as the primary cause of hyponatremia.She was discharged on hydrocortisone and levothyroxine with endocrinology and nephrology follow-up.

Discussion

Sheehan syndrome can present acutely or,in a delayed course with symptoms like fatigue,weakness, hyponatremia,hypoglycemia,or adrenal crisis.Diagnosis is often missed or delayed as symptoms are attributed to more common conditions like depression or primary hypothyroidism.Radiologic findings of an empty sella, together with a history of postpartum hemorrhage and biochemical evidence of pituitary hormone deficiency,strongly support the diagnosis.
This case underscores the importance of maintaining a high index of suspicion for Sheehan syndrome in patients with unexplained hyponatremia or adrenal insufficiency and a remote history of obstetric hemorrhage.Prompt recognition and timely hormone replacement are essential to reduce morbidity and improve long-term outcomes and quality of life.