1. INTERESTING CASE OF ANAEMIA
S.DHANRAJ PG M2
DR.SUNDARAMURTHY’S UNIT

2. • 40 YRS OLD MRS.SARASU CAME WITH
C/O on 4/4/13
Decreased urine output – 15 days
-- gradual
-- 300ml/day
Abdominal pain -- 6 months
-- pricking,more towards
epigastric region,not radiating or referred,not assoc. with
any other symptoms
Fever -- on and off,10 days
-- low grade
intermittent, not assoc. with
chills,rigor,rash,bleeding tendency

3. • Leg swelling -- 15 days
-- bilateral,upto knee
No h/o abdominal distention
No h/o constipation
No h/o chest pain/ breathlesness
No h/o jaundice
h/o hair fall +
h/o easy fatigueability+
h/o loss of apetite
No h/o contact
No h/o trauma
No h/o loc, no h/o drug intake

4. • PAST HISTORY
Not a known DM/SHT/CAD
No previous admissions
• MENSTRUAL HISTORY
amenorrhea for 18 yrs

5. EXAMINATION
Drowsy
Temperature (98.4 F )
dehydrated,
Severe pallor,facial puffiness
Dry coarse skin,sparse hair in scalp
Hoarse voice
b/l pedal edema+
no clubbing,no palpable lymphadenopathy

6. CVS – s1s2+
RS -- B/L normal breath sounds
P/A– epigastric tenderness+
-- no organomegaly
CNS – drowsy ,responding to oral commands
-- Examination: able to move all four limbs
-- delayed DTR
VITALS : BP-90/60mmHg;
PR- 60/min

7. • She was initially suspected as a case of
? Chronic kidney disease with encephalopathy
and fever under evaluation

8. • INVESTIGATIONS
• CBC – HB 7.6 SR. ELECTROLYTES
TC 4500 Na-129
DC N70L27E3 K-3.7
ESR 15/35 CL-98
PCV 24 HCO3-23
MCV 83 URINE
MCH 26 ALB-NIL
MCHC 31 SUG-NIL
RBC 2.8LAC DEP-1-3PUS CELLS
PLATLETS 1L
• RFT- SUGAR 203
UREA 12
CREATININE 0.8

9. • USG– N STUDY
• CXR- PA – N STUDY
• ECG -- WNL
• ECHO -- N LV FUNCTION
• FEVER PROFILE AND BLOOD CULTURE--
NEGATIVE

10. • CLINICALLY , suspected
MYXEDEMA PRECOMA
TFT SENT and
 started on ELTROXIN 100mcg
WITH steroids

11. TFT results– FT3 - 0.37pg/ml(2.3 to 4.2pg)
FT4 – 0.41ng/dl(0.6 to 2ng)
TSH – 2.572miu/ml(1 to 5miu/ml)
ELTROXIN dose stepped up

12. INVESTIGATIONS
• 5/4/2013
Urine spot PCR– 23/13
p.smear– microcytic hypochromic anaemia
Wbc—N
Platelets– adequate
No immature cells/haemoparasite

13. • Reticulocyte count – 1.5% (0.5-1.5%)
•
• Se LDH 190 U/L (135-220)
• Coomb’s test: negative
• Serum iron: 48 (50 to 150mcg/dl)
• TIBC: 380 (300-360 mcg/dl)
• Serum ferritin : 28 (30 to100mcg/dl)

14. • 7/4/13
patient started showing improvement
FURTHER INVESTIGATIONS
With TFT results (low t3, t4, normal TSH)
a pituitary cause of hypothyroid was
suspected and
PROCEEDED FOR workup for endocrine
insufficiency

15. • PROLACTIN – 0.6ng/ml (4.7 to 23.3 ng)
• LH – 0.99miu/ml
( Follicular phase:2.4-12.6
Ovulation phase:14-95.6
Luteal phase: 1-11.4 mIU/ml)
• FSH – 3.14 miu/ml
( Follicular phase: 3.5-12.5
Ovulation phase: 4.7-21.5
Luteal phase: 1.7-7.7 mIU/ml)
• CORTISOL – 0.42mcg/dl ( 6.2 – 19.4 mcg/dl)
• ACTH – 3.07pg/ml (7.2 – 63.3 pg/ml)

16. • Patient was continued with Levothyroxine
and steroids
• Patient improved dramatically

17. ON PROBING
She gave
• h/o post partum haemorrhage at 3rd delivery
• Lactation failure after 3rd delivery
• Amenorrhea for 18 years
• PROCEEDED WITH MRI BRAIN

21. FINAL DIAGNOSIS
• EMPTY SELLA SYNDROME probably due to
POSTPARTUM PITUITARY NECROSIS
(SHEEHAN’S SYNDROME)

22. INVESTIGATIONS NOT DONE
• Stimulation and provocative tests
• Posterior pituitary hormones assay
• Autoimmune work up----primary hypophysitis
(lymphocytic, granulomatous)
• Secondary hypophysitis—(infections,
sarcoidosis, takayasu)
• Haematological malignancy

23. SHEEHAN’S SYNDROME
- Postpartum hypopituitarism caused by
necrosis of the pituitary gland
- It is usually the result of severe
hypotension or shock caused by
massive hemorrhage during or
after delivery
- Usually presents as anterior pituitary
hormone deficiency
- Evolves slowly and is diagnosed late

24. - most common cause of hypopituitarism in
developing countries
- prevalence to be about 3% for women
above 20 years of age
- average time between the previous
obstetric event and diagnosis of SS was 6
to 13 years

25. MECHANISM
• Ischemic pituitary necrosis due to
severe postpartum hemorrhage
• Vasospasm, thrombosis and
vascular compression of the
hypophyseal arteries
• Autoimmunity

26. PRESENTATION

29. SYMPTOMS
• CORTICOTROPIN DEFICIENCY can cause
weakness, fatigue, hypoglycemia, or dizziness.
• GONADOTROPIN DEFICIENCY will often cause
amenorrhea, oligomenorrhea, hot flashes, or
decreased libido.
• GROWTH HORMONE DEFICIENCY causes many
vague symptoms including fatigue, decreased quality of
life, and decreased muscle mass.
• Difficulty breast-feeding or an inability to breast-feed
• HYPOTHYROIDISM
• Some women live for years with pituitary
insufficiency, can present as ADRENAL CRISIS triggered
by extreme physical stressors, such as severe infection
or surgery.

30. TREATMENT
Hormone replacement
• Hydrocortisone or prednisolone is replaced first
because thyroxine therapy can exacerbate
glucocorticoid deficiency and theoretically induce
an adrenal crisis.
• thyroxine replacement
• gonadotropin replacement
• Replacement of growth hormone is necessary in
children with hypopituitarism but is controversial
in adults.

31. REPLACEMENT
• ACTH -- Hydrocortisone
Cortisone acetate
Prednisone
• TSH – L-Thyroxine
• FSH/LH -- Females
Conjugated estrogen (0.65–1.25 mg qd for 25 days)
Progesterone (5–10 mg qd) on days 16–25
For fertility: Menopausal gonadotropins, human CG
Males
Testosterone enanthate
• GH -- Adults: Somatotropin (0.1–1.25 mg SC qd)
Children: Somatotropin [0.02–0.05 (mg/kg per day)]
• VASOPRESSIN

32. THANK YOU