[A rare cause of cardiogenic shock with psychotic symptoms]

A 40-year-old man was admitted to the emergency department with psychotic symptoms and marked hypothermia. He was known to have had a macroadenoma of the pituitary gland which had been excised 10 years before. No information about his current medication was available. Several hours after admission the patient developed signs of acute cardiac failure and cardiogenic shock. He was admitted to the intensive care unit, intubated and treated with vasoactive drugs. Later investigations revealed that the patient had stopped his hormonal therapy (hydrocortisone and thyroxine) at least 3 months previously.

Transthoracic electrocardiography revealed diffuse myocardial contractile abnormalities with an ejection fraction of 30%. Acute ischemic damage was ruled out by serial troponin-T test and electrocardiography. Severe hypothyroidism and hypocortisolism were confirmed by laboratory tests.

The diagnosis of acute pituitary insufficiency with myxedema coma and hypocortisolism was suspected and the patient was treated with parenteral cortisone and L-thyroxine. The response was favorable and the patient was extubated after 5 days. Cardiac contractility and ejection fraction normalized.

Myxedema coma can be a predominant finding of acute anterior pituitary insufficiency. There are important effects on the cardiovascular system and cerebral functions (altered mentation). Immediate diagnosis and therapy are crucial to reduce the otherwise high mortality.