Management of a patient with Sheehan’s syndrome and diabetes insipidus complicated by recurrent hyponatremia

SUMMARY: A 38-year-old female was initially seen in the intensive care unit after severe postpartum hemorrhage. She was initially diagnosed to have Sheehan’s syndrome and after discharge, she was diagnosed to have a vesicovaginal fistula which initially caused a delay in diagnosing diabetes insipidus in the patient because she was having urinary incontinence. The patient had the vesicovaginal fistula repaired and was on replacement with levothyroxine, prednisone, and desmopressin. Years after her diagnosis, the patient experienced recurrent episodes of hyponatremia in the setting of desmopressin therapy. This case highlights the challenges of diagnosing diabetes insipidus in a patient with Sheehan’s syndrome and a vesicovaginal fistula, as well as the long-term management of central diabetes insipidus in a resource-limited setting. LEARNING POINTS: Sheehan’s syndrome is rarely associated with diabetes insipidus, and in our patient, it was initially missed due to a vesicovaginal fistula which caused urinary incontinence. Water intoxication is more common in young children and older adults but can occur years after initiating treatment with desmopressin in adults and should be kept in mind when treating patients with hyponatremia who have hypopituitarism associated with diabetes insipidus. Water intoxication is much more common in patients with diabetes insipidus being treated with intranasal desmopressin than in those using the oral preparations.