Dilated Cardiomyopathy

Abstract

A 42-year-old woman presented herself to the emergency services in cardiogenic shock. She had a history of progressively worsening breathlessness for the past year; however, no medical evaluation had been performed earlier. At presentation, her pulse rate was 110 beats per minute, regular, and low volume, and her blood pressure was 90/70 mm Hg. On auscultation, third heart sound was present, but no murmurs were heard. Soon after presentation, she had an asystolic cardiac arrest. However, she was resuscitated successfully and mechanically ventilated, and she required inotropic support with dopamine and noradrenaline for maintaining blood pressure.Her ECG showed normal sinus rhythm and nonspecific ST-T changes, and chest radiograph showed cardiomegaly with features of pulmonary venous hypertension (Figure 1). Her echocardiogram showed severe left-ventricular systolic dysfunction with a left-ventricular ejection fraction of 20% ( Figure 2). Her routine blood biochemistry, including liver and renal function tests, was within normal limits, except for mild anemia with hemoglobin of 9.5 g/dl. A diagnosis of dilated cardiomyopathy with cardiogenic shock was made, and the patient was treated accordingly. Subsequently, she was weaned off the ventilator, but she continued to require inotropic support.She remained markedly symptomatic with fatigue and complained of blackouts on getting up. There was a postural drop of 25 mm Hg in systolic blood pressure on sitting up. Furthermore, it was noticed that her heart rates did not go beyond 110 beats per minute, despite being on high doses of inotropes and remaining hypotensive. On close scrutiny, patchy pigmentation of face was noticed along with loss of axillary and pubic hair.Further inquiry into her past history revealed that she had nearly bled to death in her last pregnancy 14 years ago. Since then, she had no menstruation and lactation. In light of this, she was investigated for endocrine disorder and was found to be having panhypopituitarism (Table)-thus a case of Sheehan syndrome. The diagnosis remarkably changed her management because along with cardiogenic shock, she also had additional hypoadrenal shock. She was started on glucocorticoids, thyroxine, and fludrocortisone, and within 2 days she was weaned off inotropes. Her blood pressure by guest on

Reversible Cardiomyopathy Accompanied by Secondary Adrenal Insufficiency

“…To our knowledge, no case of hypophysitis-induced secondary adrenal insufficiency along with heart failure successfully treated with cortisol replacement therapy alone has been reported in the literature. The findings of this case are consistent with those of previous cases [1][2][3] in terms of long-term fatigue that was considered normal after delivery. Therefore, adrenal insufficiency may remain undiagnosed after delivery, suggesting the possible existence of women with undiagnosed endocrine insufficiency, who may have heart failure in the future.…”

“…Few cases of reversible cardiomyopathy accompanied by Sheehan syndrome have been reported. [1][2][3] These cases have the common characteristics of a late diagnosis of Sheehan syndrome after delivery (>2 years) and recovery of cardiac function after hormone replacement therapy, including glucocorticoid therapy. One of the previous cases was initially diagnosed with peripartum cardiomyopathy and showed no improvement of cardiac function with standard medications for heart failure until hormone replacement therapy was initiated.…”

“…Considering the long-term fatigue after delivery and the results of endocrine function tests (Table) and brain magnetic resonance imaging that revealed an empty sella ( Figure 2), she was diagnosed with secondary adrenal insufficiency with idiopathic cardiomyopathy. Because cardiomyopathies accompanied by secondary adrenal insufficiency caused by Sheehan syndrome have been reported to be reversible, [1][2][3] we continued oral cortisol therapy alone, and her cardiac function gradually improved. Complete recovery of ejection fraction was noted 2 months after the start of oral cortisol therapy ( Figure 1C and 1D).…”

Cardiogenic Shock Due to Nonischemic Cardiomyopathy Induced by Severe Anterior Hypopituitarism

“…Although rare, there have been reports of late onset hypopituitarism presenting with new cardiomyopathy. Doshi et al reported a 42-year-old female with new onset cardiomyopathy secondary to hypopituitarism that occurred 14 years after a postpartum hemorrhage (20). In contrast to the present case, their patient's cardiomyopathy completely reversed with replacement hormones.…”

Hypopituitarism presenting as congestive heart failure

“…Pituitary gland has a large secretory reserve, and >75% must be destroyed before clinical manifestations of hypopituitarism are evident. [ 2 ] SS, therefore, often evolves slowly and is diagnosed late. Increased pituitary volume during pregnancy, small sella size, coagulopathy, and autoimmunity are the proposed factors in the pathogenesis of SS.…”