Ampulla (Takotsubo) cardiomyopathy caused by secondary adrenal insufficiency in ACTH isolated deficiency

We describe here a case of reversible ampulla (takotsubo) cardiomyopathy caused by secondary adrenal insufficiency in ACTH isolated deficiency. A 53-year-old woman was referred to our department for evaluation and treatment of unconsciousness. On admission, her plasma glucose level was 34 mg/dL, suggesting loss of consciousness due to hypoglycemia. Basal levels of ACTH, cortisol, and dehydroepiandrosterone sulfate in blood, and urinary free cortisol levels were all decreased. ACTH and cortisol levels were not adequately increased in response to CRH administration and the insulin tolerance test. Electrocardiography showed ST segment elevation and T wave inversion in leads V 1-6. The coronary arteries were free of organic stenosis, and a left ventriculogram revealed severe hypokinesis, particularly in the anterior and posterior walls. Based on a diagnosis of adrenocortical insufficiency caused by ACTH isolated deficiency, hydrocortisone was administered. Two weeks after treatment, ultrasound studies of the heart showed recovery of left ventricular wall motion. Activation of the sympathetic nervous system, adrenocortical failure, and hypoglycemic attack were considered to be triggering factors for the takotsubo cardiomyopathy. Careful monitoring of cardiac function and appropriate treatments for both cardiomyopathy and adrenocortical failure are required to recover cardiac dysfunction.