When I started my consultancy after passing my FCPS Medicine, at Hill Park General Hospital Karachi, in 2008. One night I received a call from ER by the ER doctor who informed me about a patient, 48 years old married female who came with diarrhea and vomiting since 5-6 days. I asked the RMO about the comorbid and there weren’t any. Then I enquired about her hydration status and the answer was of mild dehydration but the patient was stable vitally as her BP, pulse, temperature was all normal. So I admitted her in the ward and ordered to replace fluid by ringer’s lactate then normal saline and start antibiotic after sending stool culture and sensitivity, anti emetics and proton pump inhibitor and to maintain her intake and out put charts. Other routine investigations were also advised.

The following day when I went to see the patient, I first checked her file at the nursing counter. The report that made me alert was her serum sodium of 120 mEq/L. Her other panels were within normal limits.

Later when I entered the room, what I saw was a very pale middle-aged lady, lying listlessly on bed. Her facies were pointing to some grave disorder that I was not able to comprehend at that moment but the look of her, gave me a sense that there was something very wrong beside diarrhea and vomiting.

The patient was oriented but talked in a very feeble voice. Her family told me that she was bed ridden due to weakness and suffers from bouts of recurrent vomiting and diarrhea since long. Her family had become so used to her state of health that they stopped worrying, as the patient herself had no energy to complain I guess! I found that family so oblivious! Her history of complaints was going back to months.

I ordered normal saline replacement but her following day serum sodium fell further to 18 mEq/l. I checked her urinary spot sodium and it became normal and her hydration status had also normalized but there was no improvement in her general condition of asthenia and listlessness. She had metabolic acidosis with low sodium and normal serum potassium. I calculated her serum osmolality and it came out to be 272 mOsm/kg. So it was a case of Euvolumic hypotonic hyponatremia. I shifter her to ICU as her following day sodium was 113 mEq/l and immediately I arranged hypertonic saline solution to be infused very slowly as there was a risk of pontine mylenolysis if sodium is replaced rapidly. I was worried for that.

I examined her again, took her detailed history again. Her blood pressure was continuously being 90/60 mmHg so my mind had a sudden spark towards Addison’s disease! I examined her palate to find dark pigmentation but there was not any! Her sodium rose gradually to 120 mEq/l after 48 hours but again started falling the other day when hypertonic saline was stopped. So I sent the patient for short synacthin test (ACTH stimulation test) to AKUH laboratory by ambulance with a doctor. To my utmost surprise this test came out to be positive showing low serum cortisol and significant improvement on injecting ACTH during the test! Later her ACTH when checked, it was low too, so it was not a primary adrenal failure (Addison’s disease) rather it was pointing to secondary adrenal failure! I put her on injectable glucocorticoids and the following day the patient got up from bed for the first time! I enquired her obstetrical history again and on probing I got a significant history of post partum hemorrhage a decade back and following last delivery, she failed to lactate or menstruate but that was taken as normal menopause.

So next I checked all her anterior pituitary hormones. Her T3 and T4 became low plus low TSH as well so indicating towards secondary hypothyroidism. I immediately added thyroxin tablet 50 microgram/day and after a day or two the patient’s voice changed from bovine to clearer tone! She didn’t lactate after her last-born child due to low prolactin and didn’t menstruate due to low FSH and LH! So the final diagnosis I made of “Sheehan Syndrome” (Post partum pituitary necrosis)!

I put her on hydrocortisone tablet 20 mg in the morning and 10 mg in the evening plus thyroxine 50 microgram once daily. I counseled her and the family that she will need these medications through out her life and at the time of any stress like any infection, trauma or surgical procedure she will need additional dose of steroids. I also gave her a special card with the discharge card indicating the diagnosis and replacement therapy doses and instructed to carry it in her bag wherever she goes.

The patient had a magical improvement, for the very first time she sat up on bed first then got up from bed. Her voice became clearer. Her family could not believe that she could become so alert as they had already accepted her to be bed ridden and persistently vomiting with feeble, bovine croaky voice! Neither I had seen such a rare case nor I had seen such oblivious family members!

Dr. Zeba Hisam