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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 186-187

A case report of pancytopenia associated with sheehan's syndrome that resolved with hormone replacement


Department of Medicine, ABVIMS and Dr. RML Hospital, New Delhi, India

Date of Submission09-Dec-2021
Date of Decision28-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication13-Jul-2022

Correspondence Address:
Dr. Ajay Bhatta
R819, First Floor, New Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_138_21

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  Abstract 


Pancytopenia is an uncommon hematological finding in patients with Sheehan's syndrome. Our case is an adult female who presented after 12 years of severe postpartum hemorrhage with symptomatic hypoglycemic attacks and pancytopenia on hemogram. Hormone replacement corrected pancytopenia within a week.

Keywords: Hypopituitarism, pancytopenia, Sheehan


How to cite this article:
Bhatta A, Singh R, Chawla R, Pradeep M. A case report of pancytopenia associated with sheehan's syndrome that resolved with hormone replacement. Indian J Med Spec 2022;13:186-7

How to cite this URL:
Bhatta A, Singh R, Chawla R, Pradeep M. A case report of pancytopenia associated with sheehan's syndrome that resolved with hormone replacement. Indian J Med Spec [serial online] 2022 [cited 2022 Aug 9];13:186-7. Available from: http://www.ijms.in/text.asp?2022/13/3/186/350770




  Introduction Top


Sheehan's syndrome is a syndrome of anterior pituitary hormones' deficiency due to pituitary ischemia after massive postpartum hemorrhage (PPH). Anemia is recognized as a common hematological feature of hypopituitarism, whereas pancytopenia is an uncommon hematological manifestation of Sheehan's syndrome. We describe an uncommon hematological finding in a patient with Sheehan's syndrome.


  Case Report Top


A 40-year-old married female was brought to the emergency department with complaints of multiple episodes of generalized tonic–clonic seizures (GTCS) followed by altered sensorium for the past 5 days. There was no history of fever/headache/ear discharge/head injury. General physical examination revealed pallor, pulse rate of 90/min, and blood pressure of 80/60 mmHg. Systemic examination was within normal limits. Her random blood sugar at the time of presentation was 36 mg/dL, which was immediately corrected with dextrose infusion. Noncontrast computed tomography of the brain revealed no abnormality and other basic investigations were sent. History revealed PPH 12 years back, following which there was failure to lactate her baby and she was amenorrhic since then. Secondary sexual characters were poorly defined including breast hypotrophy and lack of pubic and axillary hair.

Blood investigations revealed hemoglobin of 7.2 g/dL, total leukocyte count of 1700, and platelet count of 50000/cumm, suggesting pancytopenia. Liver and kidney function tests were within normal limits. Serum B12/folate levels and iron profile were normal. Antinuclear antibodies and direct and indirect Coomb's test were also negative. Her hormone profile revealed low growth hormone, luteinizing hormone, follicle-stimulating hormone, prolactin, cortisol, free triiodothyronine, and thyroxin. Thyroid-stimulating hormone was low normal [Table 1]. Contrast-enhanced magnetic resonance imaging (MRI) brain findings suggested hypotrophy of anterior pituitary consistent with Sheehan's syndrome [Figure 1].
Table 1: Hormone profile of the patient

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Figure 1: Contrast-enhanced magnetic resonance imaging brain showing hypotrophy of anterior pituitary with partially empty sella

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The patient was started on levothyroxine, hydrocortisone, and calcium supplementation. The patient responded, and her hemogram was normal on day 7 with a normal blood pressure when she was discharged. She was followed up after 1 month and is currently doing well.


  Discussion Top


Our patient presented with symptomatic hypoglycemia presenting as GTCS, and her hemogram revealed pancytopenia. Thorough history and physical examination gave a clue toward hypopituitarism which was later confirmed by hormone profile and MRI brain. However, the cause of pancytopenia was not explained and search for the same was continued. After ruling out possible causes of pancytopenia and looking back at literature, it was observed that pancytopenia was associated with Sheehan's syndrome. Normalization of hemogram following hormone supplementation further strengthened the association.

Sheehan's syndrome is a syndrome of hypopituitarism due to severe PPH, which presents with features such as lactation failure, amenorrhea, involution of breasts, loss of axillary and pubic hair, and features of other pituitary hormone deficiencies.[1],[2],[3] Hematological abnormalities have not been paid much attention to in patients with Sheehan's syndrome. Anemia is recognized as a common hematological feature of hypopituitarism. Hypothyroidism, adrenal insufficiency, and gonadal hormonal deficiency can explain normochromic anemia in hypopituitarism.[4] However, pancytopenia is uncommonly observed in Sheehan's syndrome. Loss of effect of pituitary hormones on metabolic reactions to hematopoiesis, which is related to hypopituitarism, has been postulated as a possible cause of pancytopenia.[4],[5] In a study by Gokalp et al.,[6] they reported hematological abnormality in 65 patients where anemia, bicytopenia, and pancytopenia were seen in 52, 14, and 1 patients, respectively.


  Conclusion Top


Pancytopenia is an uncommon hematological abnormality in Sheehan's syndrome. When present, it shows complete recovery after hormone replacement. Therefore, in women with pancytopenia with a history of severe PPH, Sheehan's syndrome may be suspected as a treatable cause.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zargar AH, Singh B, Laway BA, Masoodi SR, Wani AI, Bashir MI. Epidemiological aspects of postpartum pituitaryhypo function (Sheehan's syndrome). Fertil Steril 2005;84:523-8.  Back to cited text no. 1
    
2.
Kelestimur F. Sheehan's syndrome. Pituitary 2003;6:181-8.  Back to cited text no. 2
    
3.
Zargar AH, Masoodi SR, Laway BA, Shah NA, Salahuddin M, Siddiqi MA, et al. Clinical spectrum of Sheehan's syndrome. Ann Saudi Med 1996;16:338-41.  Back to cited text no. 3
    
4.
Kim DY, Kim JH, Park YJ, Jung KH, Chung HS, Shin S, et al. Case of complete recovery of pancytopenia after treatment of hypopituitarism. Ann Hematol 2004;83:309-12.  Back to cited text no. 4
    
5.
Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH. Sheehan's syndrome with pancytopenia – Complete recovery after hormone replacement (case series with review). Ann Hematol 2010;89:305-8.  Back to cited text no. 5
    
6.
Gokalp D, Tuzcu A, Bahceci M, Arikan S, Bahceci S, Pasa S. Sheehan's syndrome as a rare cause of anemia secondary to hypopituitarism. Ann Hematol 2009;88:405-10.  Back to cited text no. 6
    


    Figures

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    Tables

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