Endocrine Abstracts

Background: We present a rare diagnosis of a patient presenting with Takotsubo cardiomyopathy and pituitary apoplexy. The case highlights the difficulty in management of a cardiac event with bleeding risk in a patient with these associated diagnoses.

Case report: An 85-year-old woman was admitted to hospital with a severe frontal headache that woke her from sleep. She described chest pain associated with breathlessness later and was mildly confused. Sadly, her husband had passed away recently. She was on edoxaban. The neurological examination was normal with intact visual fields on direct confrontation. A formal visual fields could not be done due to confusion. A CT head and later MRI pituitary were performed and confirmed apoplexy with a likely adenoma just underlying the chiasm. She was started on hydrocortisone immediately. Electrocardiogram showed flutter with variable block, as well as T wave inversion in lead V6. The initial Troponin Ts were 312 and 317ng/l (<14ng/l). She was admitted to the cardiology ward and Aspirin and Clopidogrel were started for non-ST elevation myocardial infarction. Her Edoxaban was stopped prior to the MRI. Echocardiogram showed features of Takotsubo cardiomyopathy. After a discussion in the pituitary MDT, it was agreed with cardiology to continue Clopidogrel only and manage her conservatively. A pituitary MRI was requested to de done in 6 weeks for surveillance.

Discussion: There are only a few case reports of Takotsubo cardiomyopathy precipitated by a pituitary apoplexy. The challenges in managing the bleeding risk with an elevated troponin are obvious. This case showcases that a careful, individualised, multi-disciplinary approach is required to make safe treatment decisions. It is also essential to discuss the risks and benefits with the patient and family so an informed collaborative decision is made in this rare scenario.