Post-partum pituitary insufficiency and livedo reticularis presenting a diagnostic challenge in a resource limited setting in Tanzania: a case report, clinical discussion and brief review of existing literature

Abstract

BackgroundPituitary disorders following pregnancy are an important yet under reported clinical entity in the developing world. Conversely, post partum panhypopituitarism has a more devastating impact on women in such settings due to high fertility rates, poor obstetric care and scarcity of diagnostic and therapeutic resources available.Case presentationA 37 year old African female presented ten years post partum with features of multiple endocrine deficiencies including hypothyroidism, hypoadrenalism, lactation failure and secondary amenorrhea. In addition she had clinical features of an underlying autoimmune condition. These included a history of post-partum thyroiditis, alopecia areata, livedo reticularis and deranged coagulation indices. A remarkable clinical response followed appropriate hormone replacement therapy including steroids. This constellation has never been reported before; we therefore present an interesting clinical discussion including a brief review of existing literature.ConclusionPost partum pituitary insufficiency is an under-reported condition of immense clinical importance especially in the developing world. A high clinical index of suspicion is vital to ensure an early and correct diagnosis which will have a direct bearing on management and patient outcome.

Pituitary injury and persistent hypofunction resulting from a peripartum non-hemorrhagic, vaso-occlusive event

“…The present patient not only presented with secondary amenorrhea in the absence of other puerperal risk factors, but she also had radiologic imaging suggestive of injury at the pituitary level (7) . The pituitary undergoes many anatomic and physiologic changes during pregnancy, mainly to accommodate enlarging lactotrophs, which makes it vulnerable to many pregnancy-related disorders (7) . Defects at the level of the hypophysis are best visualized on MRI.…”

Alopecia universalis in a patient with Sheehan's syndrome

“…[ 5 ] Alopecia areata has rarely been reported with hypopituitarism related to idiopathic primary hypophysitis and Sheehan's syndrome. [ 6 7 ] Alopecia universalis has been reported with dysfunction of hypothalamic–pituitary–adrenal axis in triple H syndrome in few cases and the mechanism involved is thought to be autoimmune. [ 8 ] The association of panhypopituitarism due to Sheehan's syndrome and alopecia universalis in our patient can be explained by autoimmunity, which could be an etiological factor for both.…”