Life-threatening stress-induced cardiomyopathy combined with acute adrenal crisis

Stress-induced cardiomyopathy, also known as Takotsubo cardiomyopathy and left ventricular apical ballooning syndrome, is characterized by transient systolic dysfunction of the apical and mid-segments of the left ventricle with the abscence of coronary occlusion. This disease typically occurs in postmenopausal women of an advanced age after emotional or physical stress. Although the prognosis is generally favorable, acute fatal complications have been reported in a small subset of patients. Some patients died with acute cardiac complications, on the other hand, other patients died with underlying critical illness which triggered stress-induced cardiomyopathy. It was noted that underlying diseases can determine the short-term prognosis of stress-induced cardiomyopathy rather than cardiac death. We present a case of life-threatening stress-induced cardiomyopathy combined with acute adrenal crisis that was successfully recovered with hydrocortisone replacement therapy.  An 81-year old woman with a history of hypertension, diabetes mellitus, and stable angina presented to the emergency department with severe chest discomfort and dyspnea (NYHA FC IV). Her daughter told that she had suffered from chest discomfort because of herpes zoster for several weeks and had been complaining of general weakness and loss of appetite for about five months. The patient had undergone percutaneous coronary intervention at right coronary artery (RCA) due to unstable angina 1.5 years ago. On admission, blood pressure was 130/80 mmHg and heart rate was 140 beats/min. Electrocardiography (ECG) showed sinus tachycardia with negative T waves in leads I, II, III, aVF and V4-6. However, 2 hours later, she looked pale and her mental status was confused. Thereafter, she was needed to intubate mechanically for severe dyspnea and pulmonary edema. Her blood pressure was dropped up to 80/60 mmHg and heart rate was 120 beats/min. Her blood gas analysis and serum electrolyte showed severe metabolic acidosis (pH