Panhypopituitarism Mimicking Acute Coronary Syndrome

Abstract

A 59-year-old man suspected of having myocardial infarction with sinus bradycardia, a decreased blood pressure, and ST-change on an electrocardiogram was referred to our hospital's emergency department. Emergent coronary angiography revealed no significant findings. However, the patient experienced shock and required intensive care. Curiosity rose when his urination volume was not disturbed; we suspected hormonal abnormalities. A hormonal examination and imaging analysis revealed panhypopituitarism caused by a Rathke's cyst. Appropriate hormonal replacement therapy improved his symptoms and led to normalization of his electrocardiogram findings. Acute coronary syndrome (ACS) is a fatal disease; however, clinicians must not discount panhypopituitarism, as it may mimic ACS symptoms.

Keywords: Rathke's cyst; acute coronary syndrome; panhypopituitarism.

Figure 1.

The electrocardiogram at arrival. ST-segment elevation in leads II, III, and aVF (black arrow) and flattened T-wave in all leads with sinus bradycardia at a rate of 44/min are shown. Reciprocal changes were not evident. Low voltage in limb leads was seen.

Figure 2.

Emergent coronary angiography. (A) Left coronary artery. (B) Right coronary artery. In both arteries, no significant stenosis or vasospasm was seen.

Figure 3.

Insulin-TRH-LHRH test. (A) TSH did not respond to TRH stimulation, but PRL slightly respond. (B) Plasma LH and FSH did not respond to LHRH stimulation. (C) Cortisol did not respond to insulin-induced hypoglycemic stimulation while ACTH did respond. (D) GH did not respond to insulin-induced hypoglycemic stimulation.

Figure 4.

Brain MRI scan image. (A) T1-weighted sagittal image, (B) T1-weighted coronal image, (C) T2-weighted coronal image, (D) T1-weighted post-gadolinium sagittal image, (E) T1-weighted post-gadolinium coronal image. The T1-weighted image indicated slight hyperintensity, and the T2-weighted image showed a remarkably hyperintense cystic lesion in the seller region (yellow arrow). No contrast enhancement of the cyst was seen; however, a thin, enhancing rim of surrounding compressed pituitary tissue was apparent (yellow arrow). The normal T1 posterior pituitary bright spot had disappeared; however, this did not indicate the presence of central diabetes insipidus (see the text).

Figure 5.

Electrocardiogram findings at three months after hormone replacement therapy initiated. Elevated ST-segment in leads II, III, aVF became normalized (black arrow).