reversible left ventricular ( lv ) dysfunction and takotsubo 's cardiomyopathy has been described in endocrine conditions such as addison 's disease , isolated adrenocorticotropic hormone deficiency , primary adrenal insufficiency in adrenal crisis , pheochromocytoma , thyrotoxicosis , and multiple endocrine neoplasia . it has also been described in various neurological conditions such as stroke , guillian  barre syndrome , seizures , subarachnoid bleed empty sella syndrome , and reversible posterior leukoencephalopathy syndrome . the most common cause of secondary adrenal insufficiency is a tumor of the hypothalamic - pituitary region , usually associated with panhypopituitarism caused by tumor growth or treatment with surgery or irradiation .
however , takotsubo 's cardiomyopathy in a case of the pituitary tumor with secondary adrenal insufficiency has not been described to the best of our knowledge .
a 48-year - old man with no known comorbid illness , presented to the emergency department with a progressive decrease in vision and headache for 2 months , vomiting for 1 day , and acute onset altered sensorium for 4 h. at admission , the patient was unresponsive with glasgow coma scale score of 6/15 ( e1m4v1 ) .
he was resuscitated with intravenous ( iv ) fluids ( 2.0 l of crystalloid and 1.0 l of colloid within 1 h ) and vasopressors ( noradrenaline infusion at 0.2 mcg / kg / h ) .
laboratory evaluation revealed hyponatremia ( 108 meq / l ) and hyperkalemia ( 5.5 meq / l ) .
the temperature was 36c . in view of the progressive loss of vision and altered sensorium , contrast
it revealed a dense sellar - suprasellar mass lesion extending into the hypothalamus , right cavernous sinus , and anteriorly under the frontal lobe of size 40 mm  23 mm .
hormonal profile revealed hypocortisolism [ table 1 ] . a provisional diagnosis of hypopituitarism with secondary adrenal insufficiency in adrenal crisis was considered .
hormonal profile of the patient resuscitation was continued , and central venous pressure ( cvp ) was maintained between 8 and 10 cm of h2o .
after adequate fluid replacement ( cvp-12 ) , noradrenaline infusion ( 0.5 mcg / kg / h ) , and dobutamine ( 3 mcg / kg / h ) infusions were started . despite continuing active resuscitation and hormonal replacement , there was persistent hypotension , tachycardia , and worsening acidosis .
a 12 lead ecg revealed sinus tachycardia with t wave inversion and st - elevation in lead 1 , 2 , avf , avl , v1-v6 , poor r wave progression in v1-v4 [ figure 1 ] .
serum biomarkers showed borderline elevation ( troponin i - 0.55 ng / ml and cpk - mb -264 ) .
bedside transthoracic echocardiography revealed regional wall motion abnormality involving the left anterior descending artery territory with ejection fraction ( ef ) < 40% [ figure 2 ] .
an acute coronary event was suspected , and the patient was started on antiplatelets and anticoagulant ( aspirin 300 mg , clopidogrel 600 mg , and iv heparin 600 iu / h ) .
electrocardiogram changes at the time of hypotension left ventricular angiogram ( a ) hyperkinetic base ( b ) akinetic apex the patient developed two episodes of ventricular tachycardia , which reverted to sinus rhythm following defibrillation . in view of the refractory hemodynamic instability ,
coronary angiogram showed normal coronaries and ventriculogram revealed apical ballooning of left ventricle and severe lv dysfunction with an ef of < 30% [ figure 3 ] .
inotropic supports were slowly tapered over 24 h and stopped . ( a and b ) angiogram demonstrating normal coronaries beta - blocker therapy was initiated with atenolol 25 mg bd .
the patient was weaned off mechanical ventilation and was continued on replacement doses of hydrocortisone and fludrocortisones .
an echocardiogram was done after 7 days showed no wall motion abnormalities and complete recovery of lv function ( ef 54% ) .
stress cardiomyopathy , also referred to as takotsubo 's cardiomyopathy or lv apical ballooning syndrome , is a clinical syndrome which manifests as chest pain , st segment elevation , mild elevation of cardiac enzyme , biomarker levels , and transient apical systolic lv dysfunction .
approximately , 1.22.2% of admissions for acute myocardial infarction have been ultimately diagnosed to be apical ballooning syndrome due to various etiologies .
emotional stress and the corresponding increase in catecholamines have been reported in many patients following takotsubo 's cardiomyopathy . proposed mechanisms for catecholamine - mediated stunning in stress
cardiomyopathy include epicardial spasm , microvascular dysfunction , hyperdynamic contractility with midventricular or outflow tract obstruction , and direct effects of catecholamines on cardiomyocytes .
recent reviews have proved that the apical ballooning that characterizes takotsubo 's cardiomyopathy reflects toxic high local concentrations of catecholamines and not coronary artery or microvascular disease .
the elevated catecholamine levels have been shown to cause direct myocyte injury via an increase in intracellular calcium and oxygen - free radicals .
the pattern of lv dysfunction may result from both myocardial cellular rupture and withdrawal of beta - adrenoceptors .
another proposed mechanism is that the cardiac functional and ecg abnormalities in takotsubo cardiomyopathy might reflect activation of central neurogenic mechanisms analogous to those evoked by subarachnoid hemorrhage .
myocardial histopathological findings seen in acute myocardial dysfunction associated with brain injury are similar to that of takotsubo 's cardiomyopathy .
although a reversible syndrome , it can lead to complications such as left heart failure , lv intracavitary obstruction , and arrhythmias . in extreme cases , it can lead to sudden and unexpected death .
patients with hypopituitarism presenting with hemodynamic instability present a diagnostic dilemma as to whether it is primarily an addisonian crisis or a myocardial event . in this case , there was an acute hemodynamic worsening , with inverted t waves and elevated cardiac biomarkers indicative of a cardiac event , soon after the initial stabilization of the addisonian crisis .
although the clinical picture resembled myocardial ischemia , coronary angiography did not reveal any obstructive lesions and prompt resuscitation and supportive measures helped in the management of a potentially lethal condition .
therefore , in patients with pituitary adenoma with panhypopituitarism , cardiac dysfunction due to hyper catecholaminergic states may present as potentially reversible conditions such as takotsubo 's cardiomyopathy . with more reports of neurological conditions either precipitating or presenting as takotsubo 's cardiomyopathy
being reported , it is to be an important differential diagnosis in patients with neurological conditions presenting with hemodynamic instability .
although the exact pathogenesis is as yet unclear , the relationship between cardiac dysfunction secondary to neurological conditions is being firmly established .
 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 . 
Introduction
Case Report
Discussion
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