title: Repairing a "broken heart" with hormone replacement therapy: case report of cardiogenic shock due to undiagnosed pituitary insufficiency.
abstract: OBJECTIVE
  To indicate cardiogenic shock as a very rare but serious clinical consequence of untreated panhypopituitarism attributable to Sheehan syndrome; to emphasize the importance of eliciting a detailed endocrine and obstetric history in women presenting with idiopathic heart failure; to highlight the diagnostic shortcomings of screening for thyroid dysfunction solely with thyroid-stimulating hormone determinations; and to report the reversibility of severe heart failure induced by long-term pituitary insufficiency.
  
  
  METHODS
  Described is a case report of a 35-year-old woman who presented with severe congestive heart failure, hypotension, and confusion. Her 2-dimensional echocardiogram revealed appreciable systolic and diastolic dysfunction. In screening for possible endocrine causes of heart failure, a normal thyroid-stimulating hormone level of 0.72 mIU/L (reference range, 0.35 to 5.5) was unremarkable; however, a profoundly low free thyroxine level of 0.12 ng/dL (reference range, 0.9 to 1.8) led clinicians to pursue a work-up of central hypothyroidism.
  
  
  RESULTS
  Endocrine testing confirmed the presence of panhypopituitarism and adrenal insufficiency. Magnetic resonance imaging of the brain revealed empty sella syndrome. Further questioning of the patient revealed a history of extensive postpartum bleeding 15 years earlier, failure to lactate, and secondary amenorrhea--all consistent with undiagnosed Sheehan syndrome. In the hospital, the patient was treated with intravenously administered corticosteroids and levothyroxine. Her mental status and symptomatic heart failure improved dramatically. After 9 months of oral levothyroxine and glucocorticoid therapy, the patient remained asymptomatic, and repeated echocardiography indicated completely normalized cardiac function.
  
  
  CONCLUSIONS
  Severe heart failure and cardiogenic shock can be a very rare (but fortunately reversible) complication of long-standing panhypopituitarism resulting from undiagnosed Sheehan syndrome.
authors.affiliation: Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University, St. Louis, Missouri 63110, USA.
authors.forename: Shunzhong S
authors.initials: SS
authors.lastname: Bao
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Fisher
mesh_terms: D000328:Adult; D003221:Confusion / Q000209:etiology / Q000517:prevention & control; D057210:Delayed Diagnosis / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006333:Heart Failure / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D020249:Hormone Replacement Therapy; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D007018:Hypopituitarism / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology*; D007022:Hypotension / Q000209:etiology / Q000517:prevention & control; D011241:Prednisone / Q000627:therapeutic use; D012720:Severity of Illness Index; D012770:Shock, Cardiogenic / Q000209:etiology* / Q000517:prevention & control; D013974:Thyroxine / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005938:Glucocorticoids; D013974:Thyroxine; D011241:Prednisone; D006854:Hydrocortisone