Deep vein thrombosis in a patient of Sheehan's syndrome: Autoimmunity or hypercoagulabilty
We present a 30-year-old female who presented with 1 month history of gradual onset swelling and pain involving the left leg. Physical examination revealed features of hypothyroidism, blood pressure of 100/70, pulse of 68/min and normally palpable peripheral pulses. The cardiovascular and respiratory system examination was normal. The left calf diameter was 5 cm greater than the right. Laboratory investigations revealed normocytic normochromic anemia, normal liver and kidney function test. Patient's blood glucose was 72 mg/dl; normal serum electrolytes; normal chest X-ray. Electrocardiogram revealed low voltage complexes with normal sinus rhythm. Doppler lower limbs revealed thrombosis in left popliteal vein. Patient's coagulation profile revealed normal prothrombin time of 12 s, activated partial thromboplastin time (APTT) of 30 s, positive D-dimer, negative protein C and protein S and normal titres of antinuclear antibodies. Echocardiography showed an ejection fraction of 52 percent. Patient was initially treated with heparin followed by warfarin. Endocrinology consultation was sought in view of clinical suspicion of hypothyroidism. Endocrinology review revealed a significant past history of primary postpartum hemorrhage, lactation failure and secondary amenorrhea since the delivery of the last child 6 years back. She had clinical features of growth hormone, thyroid hormone and adrenocorticotropic hormone deficiency. Hormonal analysis showed features of central hypothyroidism, secondary adrenal insufficiency and growth hormone deficiency which was confirmed by insulin tolerance test []. Patient was put on thyroxine; prednisolone and anticoagulants were continued for 3 months. Patient is regularly following in the endocrinology OPD with no further recurrence of DVT.