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

A 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.Post 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.The pituitary gland undergoes major anatomic, physiologic and immunologic changes during pregnancy. Its enlargement is chiefly attributed to lactotroph hyperplasia [1]. These changes then predispose the pregnant woman to a spectrum of pituitary disorders in the intra-partum and post-partum periods. These include Sheehan’s syndrome which is by far the commonest, lymphocytic hypophysitis and rarely, apoplexy of pituitary adenomas [1,2].Sheehan’s syndrome (SS) is becoming increasingly rare in the developed world due to improved standards of obstetric care; the same is not yet true for the developing world. The prevalence of women of reproductive age with suspected SS in the Kashmir valley (Indian subcontinent) was estimated at 3.2% [3]. Similar cross-sectional studies are virtually non-existent for Africa but a couple of case series have appeared in the literature. Cénac et al reported 40 cases of SS within a 5-year period at a hospital in Niger. All their patients were black African women living in rural areas and had no medical assistance during th