Takotsubo cardiomyopathy in a patient with pituitary adenoma and secondary adrenal insufficiency.

Singh, Georgene; Manickam, Ari; Sethuraman, Manikandan; Rathod, Ramesh Chandra

We describe a case of Takotsubo cardiomyopathy in a case of pituitary macroadenoma in acute adrenal crisis. A 48-year-old man presented with acute onset altered sensorium, vomiting, and gasping. On admission, he was unresponsive and hemodynamically unstable. He was intubated and ventilated and resuscitated with fluids and inotropes. The biochemical evaluation revealed hyponatremia, hyperkalemia, and hypocortisolism. Hyponatremia was corrected with 3% hypertonic saline. Contrast enhanced computed tomography (CT) scan of the brain revealed a sellar-suprasellar mass with hypothalamic extension with no evidence of pituitary apoplexy. A diagnosis of invasive pituitary adenoma with the Addisonian crisis was made and steroid replacement was initiated. Despite volume resuscitation, he had persistent refractory hypotension, recurrent ventricular tachycardia, and metabolic acidosis. Electrocardiogram (ECG) showed ST elevation and T-wave inversion in lateral leads; cardiac-enzymes were increased suggestive of acute coronary syndrome. Transthoracic echocardiography showed severe regional wall motion abnormalities (RWMAs) involving left anterior descending territory and low ejection fraction (EF). Coronary angiogram revealed normal coronaries, apical ballooning, and severe left ventricular dysfunction, consistent with a diagnosis of Takotsubo's cardiomyopathy. Patient was managed with angiotensin-converting enzyme inhibitors and B-blockers. He improved over few days and recovered completely. At discharge, ECG changes and RWMA resolved and EF normalized to 56%. In patients with Addisonian Crisis with persistent hypotension refractory to optimal resuscitation, possibility of Takotsubo's cardiomyopathy should be considered. Early recognition of association of Takotsubos cardiomyopathy in neurological conditions, prompt resuscitation, and supportive care are essential to ensure favorable outcomes in this potentially lethal condition.

ADRENERGIC beta blockers; ACE inhibitors; HYPERTONIC saline solutions; ACIDOSIS; ARTIFICIAL respiration; COMPUTED tomography; ECHOCARDIOGRAPHY; ELECTROCARDIOGRAPHY; HYPONATREMIA; HYPOTENSION; PITUITARY tumors; VENTRICULAR tachycardia; VOMITING; SENSORY disorders; ACUTE coronary syndrome; ADRENAL insufficiency; TAKOTSUBO cardiomyopathy; HYPERKALEMIA; CORONARY angiography; VENTRICULAR ejection fraction; DISEASE complications; THERAPEUTICS

Indian Journal of Critical Care Medicine, 2015, Vol 19, Issue 12, p731

0972-5229

Academic Journal

10.4103/0972-5229.171410