A Challenging Diagnosis of Sheehan’s Syndrome in Non-obstetric Critical Care and Emergency Settings: A Case Series of Five Patients with Varied Presentations

	Case 1	Case 2	Case 3	Case 4	Case 5
Demographics
Age (years)	41	34	28	54	53
Weight (Kg)	65	45	56	47	53
Height (cm)	150	148	147	159	144
Co-morbidities	Epilepsy	No	No	No	Systemic hypertension
PPH	Yes	Yes	Yes	Yes	Yes
Hysterectomy	Yes	Yes	No	No	No
Amenorhoea	Yes	Yes	Yes	No	Yes
Agalactia	Yes	Yes	Yes	Yes	No
Delay in diagnosis post-PPH (years)	8	3	2	20	18

Clinical presentation
Encephalopathy	Yes	Yes	Yes	Yes	Yes
Hypotension	Yes	Yes	Yes	Yes	No
Vasopressors	Yes	Yes	No	No	No
Bradycardia	Yes	Yes	Yes	Yes	No
LV dysfunction (2D ECHO)	Yes (LVEF 40%)	Yes (LVEF 30%)	No	No	No
MV	No	Yes	No	No	No
AKI	Yes	No	No	No	No
Polyuria	Yes	No	No	No	No
Hypoglycemia	Yes	No	Yes	Yes	No
Hematological dysfunction	Yes	No	Yes	Yes	No
Labs at admission
Hb (g/dl)	7.4	10.4	9.3	8.8	12.3
TLC ( /mm3)	3800	5700	6100	11000	4500
Platelets (lacs/ mm3)	0.75	5.1	0.75	5.5	3.5
Urea/Creatinine (mg/dl)	21/1.0	22/0.5	-/0.7	28/0.6	-/0.5
Na (mEq/L)	119	131	113	127	118
K (mEq/L)	4.2	4.04	3.84	5.0	3.3
T Bil	0.61	0.35	-	0.68	0.83
D bil	0.31	0.25	-	0.30	0.39
SGOT/SGPT	93/47	24/10	/90	24/29	104/34
ALP	411	219	-	112	35
Procalcitonin (micg/L) (N: 0-0.05)	0.11	0.73	-	-	-
Pro-BNP (pg/ml) (N: 0-125)	294	7880	-	-	-
USG abdomen	Post-hysterectomy with bilateral adnexal mass with complex septated cystic lesion.	Post-hysterectomy with very minimal pockets of collection. Abdominal drain in position.	Small uterus size	-	Mild left sided pleural effusion

Hormones	Baseline values	Case 1	Case 2	Case 3	Case 4	Case 5
Human GH by CLIA (ng/ml)	Females: 0-8	-	-	<0.05	-	-
LH (mIU/ml) by CMIA	Normally menstruating females:	4.9	0.01	0.29	-	-
	Follicular phase: 2.39-6.60
	Mid-cycle peak: 3.06-74.24
	Luteal phase: 0.9-9.33
	Post-menopausal females: 10.39-
	64.57

FSH (mIU/ml) by CMIA	Normally menstruating females:	9.92	0.06	1.25	2.2	1.01
	Follicular phase: 3.03-8.08
	Mid-cycle peak: 2.55-16.69
	Luteal phase: 1.38-5.47
	Post-menopausal females: 26.72-
	133.41

Estradiol (pg/ml) by CLIA	Normally menstruating females:	-	-	< 10	-	-
	Follicular phase: 21-251
	Mid-cycle peak: 38-649
	Luteal phase: 21-312
	Post-menopausal females:
	Not on HRT: < 10-28
	On HRT: < 10-144

ACTH (pg/ml) by CLIA		-	-	-	15	-

Morning serum cortisol (micg/dl) by CMIA	5-23	3.3	2.2	0.1	3.69 (15.9 stimulated)	0.83 (6.36 stimulated)

Thyroid profile by CLIA					-	-
T3 (ng/ml)	0.58-1.59	0.25	0.49	0.41
Free T4 (ng/dl)	0.8-1.8	-	-	0.17	0.67	-
T4 (micg/dl)	4.87-11.72
TSH (microIU/ml)	0.35-4.94	0.97	1.67	1.91	-	3.17
		1.11	4.08	0.22	1.99	3.6

Prolactin (ng/ml) by CLIA	Females:	0.76	0.88	1.5	8.8	-
	Non-pregnant: 2.8-29.2
	Pregnancy: 9.7-208.5
	Post-menopausal: 1.8-20.3

Age/PPH/Delay			Clinical presentation					Hormonal profile									Radiology
Year; Country; Age of patient	PPH	Delay (yrs)	Agalactia	Menstrual problem	Non-specific	Organ failures	Na	GH	PRL	Hypothyroidism			Hypogonadism		Adrenal insufficiency		Pituitary size	Sella volume (ml)
										TSH	fT3	fT4	LH	FSH	ACTH	Cortisol
2020;¹⁶ India 35y/F	yes	4	yes	yes	yes	Asthenia, anaemia	↓	-	↓	↓	↓	↓	↓/N	↓	-	↓	↓	-

2019;¹⁷ India 36y/F	yes	7	yes	yes	yes	Myxoedema coma, Coagulopathy, Pancytopenia, Hypoglycaemia	↓	-	-	N	↓	↓	↓/N	↓/N	-	↓	-	Partially empty sella

2016; ¹⁸ India 32y/F	yes	1	yes	yes	yes	Anaemia,	-	-	-	↓	-	-	-	↓	-	↓	-	Empty sella

2013; ¹⁹ India 41y/F	yes	22	yes	yes	yes	Hypoglycaemia Asthenia	↓	-	-	-	↓	↓	-	-	↓	↓	-	-

2019;³ USA 36y/F	yes	8	yes	yes	yes	Chronic pain upper and lower limbs, Hypoglycaemia	↓		↓	N	↓	↓	↓	↓	-	↓	CSF in pituitary fossa	Empty sella

2013;²¹ Italy 64y/F	-	30	-	-	yes	Rhabdomyolysis, hypothyroidism	-		-	-	-	-	-	-	-	↓	Atrophy	-

2013;²² Nepal 38y/F	yes	5	-	yes	yes	Sparse hair, Dyspnoea, Bradycardia, Shock	↓		↓	↓	N	↓	↓	↓	-	↓	-	Empty sella

Publication timeframe:: 4 times per year
Journal Subjects:: Medicine, Clinical Medicine, Internal Medicine, other, Surgery, Anaesthesiology, Emergency Medicine and Intensive-Care Medicine