PMC3095901_01
The clinical course of a patient with postpartum hypopituitarism (Sheehan's syndrome: SS), who developed postpartum autoimmune thyroiditis (PPAT) (transient thyrotoxicosis and hypothyroidism). A 36-year-old woman delivered a full-term baby by Caesarean section (Delivery). At 1 month post partum, she visited a doctor with thyrotoxicosis (Toxico). She was negative for TRAb. However, she was positive for TPOAb and TGAb. TPOAb- and TGAb-titers increased after delivery. Her serum thyroglobulin was 72 mug/L (normal < 32 mug/L). Radioactive iodine uptake was 0.5%/24 hr (normal 10-40%). She had thyrotoxicosis (Toxico) due to painless thyroiditis (autoimmune destructive thyroiditis). Her ACTH was less than 0.4 pmol/L, and her cortisol was less than 5.5 nmol/L. She had ACTH deficiency and secondary hypoadrenalism; 20 mg hydrocortisone (HC) was started. The thyrotoxicosis subsided spontaneously. At 4 months post partum, she developed hypothyroidism (hypothyroidism) with TSH 6.6 mIU/L. At 6 months post partum, she was referred to us with easy fatigability and agalactia. She had hypothyroidism with TSH 16.8 mIU/L. She had thyrotoxicosis (Toxico) at 1-2 months post partum and then hypothyroidism (hypothyroidism) (PPAT). At 7 months, thyroxine (T4) was started. She had hypopituitarism and empty sella on MRI (SS). She is now taking 75 mug T4 and 20 mg HC daily. Normal reference ranges: TSH 0.4-4.20 mIU/L, free T3 (free triiodothyronine) 3.5-6.6 nmol/L, and free T4 (free thyroxine) 11.6-21.9 pmol/L.
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A 36-year-old Japanese woman was referred to us at 6 months post partum with easy fatigability and agalactia (Figure 1 and Table 1, 6 months). She had delivered a full-term baby by Caesarean section (Figure 1, Delivery). She visited a doctor at 1 month post partum (Figure 1 and Table 1, 1 month). A thyroid function study demonstrated that she had thyrotoxicosis; serum free T3 and free T4 levels were elevated, and serum TSH levels were undetectable (Figure 1 and Table 1, 1-2 months). She therefore had ACTH deficiency and secondary hypoadrenalism; 20 mg hydrocortisone (HC) was started (Figure 1, 1 month post partum). At 4 months post partum, she had hypothyroidism with a serum TSH of 6.6 mIU/L (Figure 1 and Table 1, 4 months). At 6 months post partum, she was referred to us with easy fatigability and agalactia (Figure 1 and Table 1, 6 months). She had hypothyroidism with a serum TSH of 16.8 mIU/L (Figure 1 and Table 1, 6 months). Figure 1 shows her clinical course. TSH of 16.8 mIU/L (Figure 1 and Table 1, 6 months, Table 2). The elevated TSH levels indicated that she had primary hypothyroidism.
Sequential magnetic resonance imaging (MRI) (T1 weighted image: T1WI) demonstrated changes of the pituitary gland. At 2 months post partum, MRI revealed a normal pituitary gland ((a1) T1WI sagittal, (a2) T1WI coronal). At 6 months post partum, MRI revealed atrophy of the pituitary gland and empty sella ((b1) T1WI sagittal, (b2) T1WI coronal). At 6 months post partum, she had empty sella on MRI. The arrows indicate the pituitary gland.
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TSH of 16.8 mIU/L (Figure 1 and Table 1, 6 months, Table 2). The elevated TSH levels indicated that she had primary hypothyroidism. At 2 months post partum, MRI had revealed a normal pituitary gland (Figure 2(a)), while, at 6 months, MRI revealed atrophy of the pituitary gland and empty sella (Figure 2(b)). 