Myxedema Coma Nested Inside Sheehan Syndrome: A Diagnosis Not to Be Missed

Myxedema crisis is a life-threatening manifestation of severe, decompensated hypothyroidism. It often presents insidiously with altered mental status, hypothermia, hypotension, bradycardia, and hypoglycemia. Sheehan syndrome is a rare but important cause of hypopituitarism, resulting from ischemic necrosis of the anterior pituitary due to severe postpartum hemorrhage. The condition may remain undiagnosed for years, with subtle symptoms gradually progressing to full-blown endocrine crises during physiological stress. We report the case of a 48-year-old woman who presented with sudden unconsciousness, hypotension, bradycardia, hypoglycemia, and hyponatremia. Her obstetric history revealed massive postpartum hemorrhage 15 years back, followed by failure of lactation and secondary amenorrhea. Physical examination revealed madarosis. Laboratory investigations confirmed central hypothyroidism and secondary adrenal insufficiency. Magnetic resonance imaging (MRI) of brain showed an empty sella turcica, supporting the diagnosis of Sheehan syndrome. She was managed with intravenous hydrocortisone and replacement dose of levothyroxine. Considering the clinical deterioration after initial improvement, levothyroxine 500 μg loading dose was given, suspecting myxedema coma, which lead to gradual improvement of sensorium and hemodynamic status. This case highlights the importance of considering myxedema coma in women with Sheehan syndrome, especially in the setting of an unexplained altered sensorium even after hydrocortisone supplementation.