CSM Pyschosis Sheehan's Syndrome

CLINICAL SOCIETY MEETING

DEPT. OF PSYCHIATRY

PSYCHOSIS -IN A CASE OF SHEEHAN’S

SYNDROME

DEMOGRAPHIC DETAILS Mrs.Murugeshwari 28/female

Xth std.

Married since 7yrs., housewife

Informant- mother R/A/C

Ist psychiatric consultation and admission

REASON FOR CONSULTATION Irrelevant talk Over familiarity Abusive and assaultive behaviour Sleep disturbance

past 1 month

ONSET AND COURSE OF ILLNESS Acute onset

Continuous

Progressive

Not precipitated by stressor

CHANGES NOTICED DURING PAST 1 MONTH

Goes to nearby houses during day and night

Talking for hrs. together Answers not pertaining to the question Pacing around home at night Doesn’t take care of child Increased anger outbursts towards child Assaultive behaviour towards family

members Laughing to self

NEGATIVE HISTORY No h/o blurring of vision, headache, vomiting No h/o Frequent micturition No h/o Intolerance to heat, excessive appetite,

palpitation H/o constipation, but no cold intolerance,

hoarse voice No h/o Fever, head injury,seizure

PAST HISTORY Diagnosed as Sheehan’s syndrome 1 ½ yrs

back

Found unresponsive at home, admitted in unconscious state

Found to have hypoglycaemia, hypotension

Corrected with ionotropics and iv fluids

INVESTIGATIONS DONE PREVIOUSLY (23/04/12)

INVESTIGATION NORMAL VALUE PATIENT’SVALUE

T3 20-70 mcg/dl 17.3 mcg/dl

T4 5.5-13.5 mcg/dl 2 mcg/dl

TSH 0.2-4.5 mIU/ml 4.17 mIU/ml

FSH 3-10 mIU/ml 0.5 mIU/ml

LH 5-18 mIU/ml 0.79 mIU/ml

CORTISOL 5-23 mcg/dl 1mcg/dl

INVESTIGATIONS DONE PREVIOUSLY

Gynaec opinion – sec. amenorrhoea

Radiology opinion – empty sella

PAST H/O

Pt. was diagnosed as Sheehan’s syndrome and supplemented with

Tab.Wysolone 40 mg 1 HS

Tab.Eltroxin 100mcg 1 OD past 1

½ years Tab. Premarin .625mg for 21 days Tab.Meprate 10mg 16th -25th day

CONDITION AT DISCHARGEAs on 02/05/12

- general condition improved

- no psychotic symptoms

FAMILY H/O

FAMILY H/O Psychiatric illness in paternal aunt

muttering ,suspiciousnessDelusion of persecution, marital infidelityOnset at 35yrs, continuous illnessCommitted suicide at 50 yrs

Psychiatric illness in paternal cousinOnset 25 yrsMuttering to selfLaughing to selfWithdrawn wandering behaviour Diagnosed as schizophrenia,on teatment

PERSONAL H/O ANC – uneventful Natal – FTND, GH

PN - uneventful

Childhood- uneventful

Scholastic – below average, discontinued Xth

Menstrual – A/M 14yrs, regular 4/30. 2 yrs of amenorrhea . LMP - 6 months back with OCP substitution

MARITAL H/O Married since 7 yrs, third degree

consanguineous

One abortion in first trimester

ANC- uneventful

Natal – FTND, GH, wt.- 3kg, no H/o prolonged labour

POSTPARTUM PERIOD Severe wt. Loss, Fatigability

Failure to feed

Slowness in day to day activity

Amenorrhea

Decreased sexual drive

PRE-MORBID PERSONALITY Emotionally stable

Self sufficient

Trusting

Warm

Enthusiastic

Extrovert type

GENERAL EXAMINATION Pt. conscious , oriented No pallor/icterus/clubbing/cyanosis/ gen.

lymphadenopathy Vitals PR-74/min, BP- 100/70 CVS- S1 S2 (+), No murmur RS – NVBS, No added sounds Abdomen- soft, no organomegaly Loss of axillary & pubic hair No thyromegaly

CNS EXAMINATION Conscious, Oriented Rt. Handed individual

RIGHT UL/LL LEFT UL/LLBULK NORMAL NORMAL

TONE NORMAL NORMAL

POWER 5/5 5/5

REFLEXES NORMAL NORMAL

PLANTAR BILATERAL FLEXOR

CNS EXAMINATION Sensory system – normal Cranial nerves - normal No cerebellar signs No gait abnormality Spine & cranium – normal

MENTAL STATUS EXAMINATION Pt. alert, ambulant In touch with surroundings Brought by attender for interview Sat in the seat offered Looks appropriate for age Dressed adequately Not groomed well Gets up frequently from the chair in between the

interview Frequently self absorbed smile noted during interview

MSE- ATTITUDE AND BEHAVIOUR

Rapport established with difficulty Gaze contact made but not maintained Psychomotor activity – increased No abnormal movements No mannerism

MSE- TALKTALK

spontaneous excessive talk

relevant

Shifts to irrelevancy

Prosody not maintained

Quantum- increased tone rate- normal

RT- normal

HIGHER MENTAL FUNCTION

Attention, concentrati

on

Arousable

Not sustain

ed

Orientation

Time

Place

Person

Memory

Recent impaire

d

General fund of

knowledge

Adequate

Abstract thinking

impaired

Judgment to test

situation

impaired

Insight – Absent

PSYCHOMETRY Tests applied Rorschach Ink blot test – less no. of

popular responses, contamination, more anatomical responses

TAT – thought disturbances noted Suggestive of psychosis - NOS

RATING SCALES YMRS – scores 17

BPRS – scores 17

PANSS POSITIVE SCALE -14 NEGATIVE SCALE – 13 GEN.PSYCHOPATOLOGY SCALE – 32

MMSC – scores 13 NEUROPSYCHOLOGICAL ASSESMENT

Impairment in executive functions Tests of memory

Immediate verbal and visual memory – intact WORKING MEMORY - impaired

Mild impairment In verbal learning & memory

INVESTIGATIONS Hb -10.2 gm/dl Urea -28 mg/dl Sugar -82mg/dl Creat – 1.2 mg/dl Na+ - 140 meq/l K+ - 4.2meq/l cl- -107meq/l Hco3- -28meq/l Urine alb-nil Urine sugar – nil Deposits – 0-3 pc/ Hpf ECG- WNL USG ABDOMEN AND PELVIS – Normal study

INVESTIGATIONS Lipid profile

sr. cholestrol – 154.68 mg/dlSr.triglycerides – 464.55 mg/dlHDL - 19.26 mg/dlLDL – 42.51 mg/dlVLDL – 92.91 mg/dl

TFT- normalT3- 1.33 ng/mlT4 – 8.28 µg/dlTSH – 0.873 µIU/ml

FSH- 3.30 mIU/ml LH – 2.01 mIU/ml Prolactin- 0.091 ng/ml (normal: 4-23 ng/ml) ACTH- 10 pg/ml

NORMAL MRI PATIENT’S MRI

MRI FINDING Anterior pituitary appears thinned out

with partial empty sella height 4mm (normal-10mm)

Posterior pituitary- bright spot could be visualised

No significant pathology/ focal lesion in brain parenchyma

DIAGNOSTIC FORMULATIONMurugeshwari 28/f ,married with c/o

irrelevant talk, over familiarity, abusive

behaviour, sleep disturbances – past 1

month, past h/o Sheehan’s synd. On steroids and HRT family h/o Schz. Illness,.

DIAGNOSTIC FORMULATION

Personal h/o amenorrhea, failure of lactation, decreased sexual drive, Loss of wt., fatigability, after delivery, GE – loss of axillary & pubic hair, MSE – decreased attention, concentration, impaired recent memory, impaired judgment & abstract thinking, absent insight.

DIAGNOSIS

Provisional diagnosis-Psychosis not otherwise specified

Treatment given• tapered steroids• Added T. Risperidone 2 mg

b.d after 4 weeks

Condition at present Psychomotor activity – normal

Talk – relevant

No psychotic features at present

No abusive /assaultive behaviour

Symptoms improved

FINAL DIAGNOSIS

Steroid induced psychosis

DISCUSSION

   REVIEW ARTICLE

Year : 2011  |  Volume : 15  |  Issue : 7  |  Page : 203-207

Sheehan's syndrome: Newer advancesC ShivaprasadDepartment of Endocrinology, M. S. Ramaiah Hospital, Bangalore, India

Date of Web Publication13-Sep-2011

SHEEHAN’S SYNDROME Sheehan’s syndrome is

characterized by varying degrees of pituitary dysfunction due to postpartum ischemic necrosis of the pituitary gland after massive bleeding.

SHEEHAN’S SYNDROME The main involvement is

decreased secretion of growth hormone (GH) and prolactin (90-100%), while deficiencies in cortisol secretion, gonadotropin and thyroid stimulating hormone (TSH) ranged from 50 to 100%. At least 75% of pituitary must be destroyed before clinical manifestations become evident.

CLINICAL FEATURES

INVESTIGATIONSHORMONES NORMAL VALUES SHEEHAN’S

SYNDROMET3 20-70 mcg/dl decreased

T4 5.5-13.5 mcg/dl decreased

TSH .2-4.5 micro IU/ml Normal or decreased

S.CORTISOL 5-23 mcg/dl decreased

FSH 3-10 micro IU/ml decreased

LH 5-18 micro IU/ml decreased

TREATMENT- HRT The goal of therapy is to replace

deficient hormones.

The treatment is essential hormone replacement: thyroxine 50mcg per day, hydrocortisone 40mg per day.

HRT Gonadotropin deficiency and hypogonadism

should be treated with a hormone replacement therapy.

For patients with diabetes insipidus, treatment of choice is 1-desamino-8-d-arginine vasopressin or desmopressin (DDAVP).

GH should be started on a low-dose regimen (0.1–0.3 mg/day

SYMPTOMS Mania and hypomania in 35% of patients

Acute psychotic disorder in 24% of patients

Depression, which is more common with chronic corticosteroid therapy, in 28% of patients

Delirium and cognitive deficits also have been reported

RISK FACTORS 1.3% of patients taking <40 mg/d

4.6% of patients taking 40 to 80 mg/d

18.4% of patients taking >80 mg/d.

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