Postpartum Cardiomyopathy and Torsades de Pointes Secondary to Hypophysitis
S Geethalakshmi *
Dr Kamakshi Memorial Hospital, Chennai, India.
Indira Chakravorty
Department of Family Medicine, Dr Kamakshi Memorial Hospital, Chennai, India.
J. Devachandran
Dr Kamakshi Memorial Hospital, Chennai, India.
*Author to whom correspondence should be addressed.
Abstract
Postpartum hypophysitis is an uncommon inflammatory disorder of the pituitary gland that may present with headache, visual symptoms, or varying degrees of hypopituitarism. Presentation with refractory shock, cardiomyopathy, central diabetes insipidus, severe adrenal insufficiency, and torsades de pointes is exceptionally unusual and may obscure timely diagnosis in the postpartum period. We report a 26-year-old woman, six months after caesarean delivery, who presented with breathing difficulty, lower abdominal pain, recurrent vomiting, weight loss, and fatigue. She had fluid-refractory hypotension requiring vasopressor support. Initial evaluation showed severe left ventricular dysfunction with an ejection fraction of 25-30%, hypokalaemia, bicytopenia, hypothyroidism, and a markedly low morning serum cortisol level of 1 microgram/dL. During magnetic resonance imaging of the brain, she developed torsades de pointes with cardiac arrest and required two cycles of cardiopulmonary resuscitation and electrical cardioversion. Magnetic resonance imaging demonstrated a partially empty sella with a flattened pituitary gland, an absent posterior pituitary bright spot, and a small optic chiasmal lesion abutting the infundibular stalk. Treatment included stress-dose hydrocortisone, vasopressin, magnesium and lignocaine infusions, electrolyte correction, ventilatory and vasopressor support, and heart-failure therapy. Following hydrocortisone initiation, haemodynamic status improved, vasopressors were withdrawn, and the ejection fraction increased to 45% within 10 days. At follow-up, left ventricular function and the QTc interval normalised, while morning cortisol levels remained low and diabetes insipidus improved with desmopressin. This case highlights a rare postpartum presentation of probable hypophysitis complicated by reversible cardiomyopathy, refractory shock, and torsades de pointes, supporting early endocrine evaluation in postpartum patients with unexplained shock.
Keywords: Postpartum hypophysitis, lymphocytic hypophysitis, hypopituitarism, adrenal insufficiency, central diabetes insipidus, postpartum cardiomyopathy, refractory shock, torsades de pointes, QTc prolongation, hydrocortisone replacement