Sheehan syndrome presented with acute renal failure associated with rhabdomyolysis and hyponatraemia

Sir, Hyponatraemia is a frequent complication of moderate to severe hypothyroidism [ 1 ]. Thus, thyroid function should be evaluated in any patient with an otherwise unexplained reduction in the plasma sodium concentration. There have been several case reports of rhabdomyolysis, which may lead to acute renal failure, associated with hypothyroidism [ 2 ]. We describe a patient with acute renal failure due to rhabdomyolysis, Sheehan syndrome and hyponatraemia. Case . A 58-year-old woman presented with confusion, severe myalgia, lower limb weakness and oliguria for 3 days prior to admission. She denied any form of strenuous muscle exercise. Her physical findings and a history of amenhorrea following massive postpartum hemorrhage 20 years previously suggested Sheehan's syndrome, and the pituitary hormonal studies revealed panhypopituitarism. She had not taken any treatment for this illness. Her laboratory findings were as follows: serum sodium 94 mmol/l, chlorine 70 mmol/l, urea 32 mg/dl, creatinine 1.3 mg/dl, aspartate aminotransferase (AST) 271 IU/l, alanine aminotransferase (ALT) 232 IU/l, creatine kinase (CK) >40 000 IU/l, lactate dehydrogenase (LDH) 2396 U/l, T4 <0.3 ng/dl, thyroid-stimulating hormone (TSH) 6.1 mIU/ml, FSH 2 miU/ml, LH 1 miU/ml, cortisol 21 μg/dl, leucocytes 30 000, C-reactive protein (CRP) 200 mg/l. Due to poor general condition of the patient, with leucocytosis and a high CRP, empiric antibiotic treatment was started for possible sepsis; however, no infection source could be found. In addition, methylprednisolone and thyroxine were started. While the sodium level was normalizing, creatinine and CK rose abruptly and oliguria developed, leading to the start of haemodialysis. Extensive intramuscular haemorrhages developed in the scapular and gluteal muscular regions ( Figures 1 and 2 ), with progressive decrease of haemoglobin levels and increase of INR. A total of 10 units of blood was transfused. Haemorrhages could not be stopped despite replacement with fresh frozen plasma. Although the patient was afebrile, leucocytosis, high CRP level and disseminated intravascular coagulopathy suggested sepsis. The patient ultimately died. We could not find any similar case presenting with intramuscular haemorrhages in the literature. Extensive intramuscular haemorrhages in the gluteal region. Extensive intramuscular haemorrhages in the scapular region. Rhabdomyolysis and acute renal failure due to hypothroidism is a rare entity. There are few reported cases in the literature [ 3–6 ]. Three important features were present in our patient, first an undiagnosed and untreated Sheehan syndrome of 20 years duration, second a severe and possibly chronic hyponatraemia associated with hypothyroidism, third, the development of severe intramuscular haemorrhages. The rhabdomyolysis was enhanced possibly due to the severe hyponatraemia. Hypothyroidism should be in the differential diagnosis in patients with acute renal failure associated with rhabdomyolysis and hyponatraemia. Prolonged hypothyroidism may increase mortality. Conflict of interest statement . None declared. 1Department of Nephrology Medical Faculty Yuzuncu Yil University, Van2 Department of Internal Medicine Medical Faculty Yuzuncu Yil University, Van3 Department of Nephrology Medical Faculty Sutcu Imam University, Kahramanmaras