A 27-year-old female developed severe bifrontal headache and photophobia 2 days after an emergency lower segment cesarean section complicated by massive postpartum hemorrhage (PPH) necessitating aggressive hemodynamic resuscitation. Thereafter, she remained euvolemic. Neurological examination, including visual fields to confrontation, cranial nerves, and fundoscopy, was normal. A noncontrast computed tomography scan on day 2 demonstrated a subtly enlarged pituitary gland with an area of focal hypodensity (Figure 1A). Over the following days, her headaches persisted despite analgesia and she developed lactation failure, but no additional clinical or biochemical features of pituitary dysfunction. Neurological examination remained unchanged. Magnetic resonance imaging on day 5 demonstrated a heterogeneous T2 signal within the enlarged pituitary gland and peripheral rim enhancement (Figure 1B–D), consistent with acute pituitary infarction (Sheehan syndrome).
Figure 1.
Computed tomography (CT) scan demonstrates a slightly enlarged pituitary gland with focal hypodensity (A). Magnetic resonance imaging (MRI) scan showing heterogeneous T2 signal (arrow) within the enlarged pituitary (B), peripheral T1 hyperintesity (C), and an intense rim of gadolinium enhancement (D).
Sheehan syndrome is a rare cause of pituitary necrosis due to severe PPH.1 Clinical presentation is variable. More frequently, patients present years later with nonspecific symptoms such as fatigue, endocrinopathies, amenorrhea, or oligomenorrhea. Acute presentations are rare and include varying combinations of headache, visual disturbance, altered consciousness, hypovolemia, electrolyte disturbance, hypoglycemia, and lactation failure.2,3 Neuroimaging in the acute phase demonstrates pituitary enlargement with peripheral contrast enhancement, while empty sella is seen months to years later.4 Headache as a predominant feature is quite rare, particularly in the absence of significant pituitary failure. While the differential diagnosis of postpartum headache is broad, our case highlights that acute Sheehan syndrome should be considered in such patients.
Footnotes
Authors’ Note: Aadil Rahim contributed to data collection and revision of the manuscript. Jonathan Baird-Gunning contributed to data collection and drafting the manuscript. David E. Ashton contributed to figure compilation and drafting the manuscript. Tobias Angstmann contributed to study concept and critical review of the manuscript. Rajat Lahoria contributed to study concept, supervision, and critical revision of the manuscript. Informed consent was obtained from the patient who is subject of the case study.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
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