Partial Sheehan’s syndrome with abdominal tuberculosis presented with pancytopenia and fluctuating thyroid profile: a case report

Abstract

Introduction: Sheehan’s syndrome is a well-recognized cause of panhypopituitarism secondary to pituitary apoplexy, followed by postpartum hemorrhage. Depending upon the degree of ischemic injury, it can be either partial or complete. Case presentation: We report an interesting case of a 35-year-old woman admitted to our hospital with complaints of abdominal distension, which was later presumed to be due to disseminated tuberculosis (TB) after excluding the possible differentials. During the treatment course, she was going through repeated attacks of hypovolemic shock and hypoglycemia due to adrenocortical insufficiency. This, along with the history of prolonged amenorrhea 4 years back due to severe postpartum hemorrhage in her last pregnancy, has led us to our diagnosis of partial Sheehan’s syndrome. After 1 month of starting steroid and anti-TB therapy, it was quite surprising when she presented with features of pancytopenia and antitubercular drug-induced hepatitis. Discussion: Sheehan’s syndrome may have a varying degree of presentation depending upon the degree of damage to the pituitary gland, which includes amenorrhea, lactation failure, adrenocortical insufficiency, hyponatremia, hypoglycemia, as well as pancytopenia in some rare instances The hormone panel especially the thyroid profile should be monitored carefully. Such cases are often challenging to deal with because of their varying degrees of presentation and the delay in diagnosis due to a lack of clinical suspicion. Conclusion: Therefore, we believe that this rare presentation of pancytopenia in Sheehan’s syndrome with fluctuating thyroid profile and abdominal TB in the background will let clinicians approach such a rare disease differently.

Lymph node tuberculosis‐associated paradoxical immune reconstitution inflammatory syndrome in a non‐HIV patient: Case report and review of literature

“…Although most patients with TB‐IRIS exhibit clinical improvement within 2 months following ATT, the timeframe for improvement varies widely. Pulmonary lesions and lymphadenopathy typically resolve after 3–18 months of ATT treatment [ 4 ]. Some individuals may benefit from a prolonged period of the intensive or continuous phase during ATT, as documented in certain cases [ 6 ].…”

“…This syndrome is characterized by severe inflammatory features of TB occurring after rapid reconstitution of the immune system [ 3 ]. It is characterized by an exaggerated and dysregulated inflammatory response to M. tuberculosis and its antigen release after a hasty killing, paired with a shift from anti‐inflammatory TH‐2 to pro‐inflammatory TH1 and TH17, leading to high levels of inflammatory cytokines [ 4 ]. A study group demonstrated significantly elevated concentrations of interleukin‐10 (IL‐10) and IL‐22 in TB‐associated IRIS patients compared with those in non‐IRIS patients with TB [ 5 ].…”

Immune reconstitution inflammatory syndrome (IRI S) in reproductive health

“…In the case of morbid entities causing immunosuppression, such as autoimmune diseases 33 , HIV infection, or neoplasms 34 , or conditions where there is a changing immune environment, such as pregnancy, childbirth 35 , or the postpartum period 36 , the appearance of IRIS is often triggered by the initiation of treatment that promotes the immune system functional recovery. In other cases, IRIS may also occur due to the superimposed presence of an infectious agent 37 .…”

Síndrome inflamatorio de reconstitución inmunológica (SIR S) en la salud reproductiva

“…En el caso de entidades mórbidas que ocasionan inmunosupresión, como las enfermedades autoinmunes 33 , la infección por el VIH o las neoplasias 34 , o bien en aquellas condiciones en que existe un ambiente inmunológico cambiante, como el embarazo, el parto 35 o el puerperio 36 , la aparición del SIRS suele ser desencadenada por el inicio de un tratamiento que favorezca la recuperación funcional del sistema inmunitario, aunque en otras ocasiones el SIRS también aparece debido a la presencia sobreagregada de un agente infeccioso 37 .…”