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.
Punnam SR, Gourineni N, Gupta V. Takotsubo cardiomyopathy in a patient with Addison disease. Int J Cardiol 2010;144:e34-6.
Ukita C, Miyazaki H, Toyoda N, Kosaki A, Nishikawa M, Iwasaka T. Takotsubo cardiomyopathy during acute adrenal crisis due to isolated adrenocorticotropin deficiency. Intern Med 2009;48:347-52.
Wolff B, Machill K, Schulzki I, Schumacher D, Werner D. Acute reversible cardiomyopathy with cardiogenic shock in a patient with Addisonian crisis: A case report. Int J Cardiol 2007;116:e71-3.
Scott IU, Gutterman DD. Pheochromocytoma with reversible focal cardiac dysfunction. Am Heart J 1995;130:909-11.
Goldman LE, Sahlas DJ, Sami M. A case of thyrotoxicosis and reversible systolic cardiac dysfunction. Can J Cardiol 1999;15:811-4.
Frustaci A, Loperfido F, Gentiloni N, Caldarulo M, Morgante E, Russo MA. Catecholamine-induced cardiomyopathy in multiple endocrine neoplasia. A histologic, ultrastructural, and biochemical study. Chest 1991;99:382-5.
Cho HJ, Kim HY, Han SH, Kim HJ, Moon YS, Oh J. Takotsubo cardiomyopathy following cerebral infarction involving the insular cortex. J Clin Neurol 2010;6:152-5.
Iga K, Himura Y, Izumi C, Miyamoto T, Kijima K, Gen H, et al. Reversible left ventricular dysfunction associated with Guillain-Barré syndrome - An expression of catecholamine cardiotoxicity? Jpn Circ J 1995;59:236-40.
Banki NM, Kopelnik A, Dae MW, Miss J, Tung P, Lawton MT, et al. Acute neurocardiogenic injury after subarachnoid hemorrhage. Circulation 2005;112:3314-9.
Mayer SA, Lin J, Homma S, Solomon RA, Lennihan L, Sherman D, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke 1999;30:780-6.
Sakihara S, Kageyama K, Nigawara T, Kidani Y, Suda T. Ampulla (Takotsubo) cardiomyopathy caused by secondary adrenal insufficiency in ACTH isolated deficiency. Endocr J 2007;54:631-6.
Papanikolaou J, Tsirantonaki M, Koukoulitsios G, Papageorgiou D, Mandila C, Karakitsos D, et al. Reversible posterior leukoencephalopathy syndrome and takotsubo cardiomyopathy: The role of echocardiographic monitoring in the ICU. Hellenic J Cardiol 2009;50:436-8.
Grawe H, Katoh M, Kühl HP. Stress cardiomyopathy mimicking acute coronary syndrome: Case presentation and review of the literature. Clin Res Cardiol 2006;95:179-85.
Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, et al. Transient left ventricular apical ballooning without coronary artery stenosis: A novel heart syndrome mimicking acute myocardial infarction. Angina pectoris-myocardial infarction investigations in Japan. J Am Coll Cardiol 2001;38:11-8.
Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F, et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): Frequency, mechanisms, and prognosis. Chest 2007;132:809-16.
Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: First series in white patients. Heart 2003;89:1027-31.
Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472-9.
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Eur Heart J 2006;27:1523-9.
Sealove BA, Tiyyagura S, Fuster V. Takotsubo cardiomyopathy. J Gen Intern Med 2008;23:1904-8.
Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy - A novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008;5:22-9.
Mori H, Ishikawa S, Kojima S, Hayashi J, Watanabe Y, Hoffman JI, et al. Increased responsiveness of left ventricular apical myocardium to adrenergic stimuli. Cardiovasc Res 1993;27:192-8.
Benarroch EE. The central autonomic network: Functional organization, dysfunction, and perspective. Mayo Clin Proc 1993;68:988-1001.
White M, Wiechmann RJ, Roden RL, Hagan MB, Wollmering MM, Port JD, et al. Cardiac beta-adrenergic neuroeffector systems in acute myocardial dysfunction related to brain injury. Evidence for catecholamine-mediated myocardial damage. Circulation 1995;92:2183-9.