FRI334 A Case Of Delayed Onset Sheehan's Syndrome With Diabetes Insipidus

Abstract

Abstract Disclosure: S. Inkollu: None. A. Estrada: None. Introduction: Sheehan's syndrome (SS) is characterized by hypopituitarism that develops due to ischemic pituitary necrosis from severe postpartum hemorrhage. The frequency of SS has declined in developed countries as the result of modern obstetric care. It may present immediately after delivery or many years later with delay up to 32 years after the inciting event.1 SS is characterized by anterior pituitary dysfunction, while diabetes insipidus (DI) is an uncommon complication with an estimated frequency of 5%.2 Here, we present a case of a 58-year-old woman with late onset SS 33 years after delivery, complicated by DI. Clinical Case: A 58-year-old female was referred to endocrine clinic for hypothyroidism with TSH 4.98 mIU/mL (0.27-4.20) and undetectable free T4 (fT4) at <0.1ng/dL (0.8-1.6). Her symptoms included fatigue, dizziness, cold intolerance, dry skin, and hair loss for the past two years. On further questioning, patient reported that she was unable to lactate or menstruate since her last childbirth 33 years ago in Thailand, but never sought evaluation since she had completed her family. She was able to breastfeed her previous 3 children. On examination, she appeared well oriented but lethargic, withdrawn and pale. Axillary and pubic hair was absent. Pituitary hormonal panel demonstrated panhypopituitarism with fT4 <0.1 ng/dL, ACTH 14.2 pg/mL (7.2-63.3), cortisol 0.5 mcg/dL (10-20), prolactin 0.9 ng/mL (4.8-23.3), insulin like growth factor-1 of 10 ng/mL (56-194) and FSH 1.2U/L (25.8-134.8 postmenopausal). MRI of the pituitary showed a partially empty sella turcica. A diagnosis of SS was made and the patient was started on prednisone and levothyroxine. Shortly after starting prednisone, she developed significant polyuria and polydipsia. Given concern for DI unmasked by steroids, she was started on desmopressin 1mcg PO daily. Workup for DI was not done due to financial stressors. She showed marked improvement in general well-being and all her symptoms with hormone replacement. Conclusion: SS is not as rare as assumed in developed countries like USA, likely due to migrant women and unawareness of physicians regarding possibility of late onset SS. DI, though uncommon, still occurs with SS and can be masked by adrenal insufficiency on initial presentation. Clinicians should be aware of this condition as early diagnosis and treatment of SS improves quality of life along with morbidity and mortality to a great extent. Reference: 1. Otsuka F, Kageyama J, Ogura T, Hattori T, Makino H. Sheehan's syndrome of more than 30 years' duration: an endocrine and MRI study of 6 cases. Endocr J. 1998 Aug;45(4):451-8. doi: 10.1507/endocrj.45.451. PMID: 9881893. 2. Keleştimur F. Sheehan's syndrome. Pituitary. 2003;6(4):181-8. doi: 10.1023/b:pitu.0000023425.20854.8e. PMID: 15237929. Presentation: Friday, June 16, 2023