Sheehan Syndrome Unmasked by Adrenal Crisis Secondary to Severe Dengue Fever

Abstract

Background: Sheehan syndrome is the infarction of a pituitary gland that has been physiologically enlarged as a result of postpartum bleeding. Agalactorrhea and amenorrhea are classic symptoms, but a constellation of manifestations occurs in both the acute and chronic forms. These manifestations can remain largely nonemergent unless Sheehan syndrome is complicated by severe adrenal dysfunction secondary to an inciting event such as dengue. We present a case of Sheehan syndrome that was uncovered in a patient with a dengue infection presenting as adrenal crisis. Case Report: A 45-year-old female presented with symptoms of acute gastroenteritis and severe dehydration. Her medical history was significant for secondary amenorrhea for 14 years after her last delivery followed by symptoms of endocrine dysfunction. At presentation, the patient was in adrenal crisis with hypotension, hypoglycemia, and hyperthermia. Dengue nonstructural protein 1 antigen was positive, along with signs of plasma leakage. Bloodwork showed bicytopenia with abnormal liver enzymes. Ultrasonography and computed tomography of the abdomen were suggestive of serositis with acalculous cholecystitis. Magnetic resonance imaging of the brain revealed an empty sella. Anterior pituitary hormone levels were significantly decreased with low serum cortisol, and the patient's thyroid profile analysis suggested secondary hypothyroidism. The final diagnosis was Sheehan syndrome presenting as adrenal crisis precipitated by severe dengue fever. The patient was managed conservatively and discharged on hormone supplement therapy. Conclusion: Sheehan syndrome is an important cause of panhypopituitarism in the developing world. Knowledge of Sheehan syndrome is important to help prevent its occurrence and reduce its resultant multifactorial effects.

Keywords: Adrenal insufficiency; dengue; hypopituitarism; neuroendocrinology; postpartum hemorrhage.