I had a chance to listen to the intriguing case presented 6/24 on @CPSolvers #VMR @andressa__k. So thrilled to hear @fernandbteich and @OpsBug tackle this with the guidance of @StephVSherman and @sargsyanz. Here are my reflections on this unusual presentation: (thread) https://twitter.com/RosenelliEM/status/1276200381861769216

Discussants did so well in approach to the labs. Excellent point by @fernandbteich on inadequacy of a "normal" brain MRI to capture pit pathology (unless huge abnormality), the cuts are just too big and you really need a pituitary MRI (these are done w thin cuts) to eval.

I heard some ?s re: TFT interpretation. This case demonstrates severe hypothyroidism. I'll make a separate tweet about that and my approach, and keep this thread to the pituitary stuff.

There are a number of unusual aspects about this case, the main ones to me are:

(1) "Normal" estradiol in a 60y old, that is quite late for ongoing ovarian fx and not consistent w menopause (unless on HRT and we are assaying HRT). Most pts w Sheehan will have amenorrhea after delivery, while some will have some ongoing menses that stop over the following

few years. Many have problems breastfeeding. This is true even if the diagnosis of hypopit is years later. Is she getting periods or on HRT? Did she devel amenorrhea s/p delivery? Was she able to breastfeed? These are some ?s that come to my mind.

If in menopause her estradiol should be undetectable, and that FSH would fit with a "central" inappropriate normal. If not menopausal, then it's even stranger: gonadotrophs are among the most sensitive to pit disruptions. She has AI and severe hypothyroidism but HPG is preserved?

In previous series of Sheehan, the HPG and GH axes were the only ones that were always affected

(2) In all other case reports of pancytopenia associated w hypopituitarism that I could briefly find, the entire pancytopenia completely resolves after treatment of the thyroid and cortisol deficiencies. Here, while her WBC improves, her Hgb gets worse and her plt only 140->180.

(PMIDs 19697029, 20798990, 21424753, 21968051, 24265336, 15064859). Therefore, her pancytopenia did not truly resolve, ?something possibly still going on with the bone marrow.

.This patient needs a pituitary MRI.

@sargsyanz's question re: remote ischemic insult 30y ago vs recent neoplastic/infiltrative/etc injury is a critical one. It's hard to presume post-partum anemia 30y ago was reflective of ischemic panhypopit-related pancytopenia that took decades to manifest in other pit axes.

Very curious to hear updates and eventually if a pit MRI is performed. If this really is Sheehan would be an important contribution to the literature to write up given the number of unusual presentation aspects. @ArsalanMedEd @Sharminzi @medrants