reversible left ventricular ( lv ) dysfunction and takotsubo 's cardiomyopathy has been described in endocrine conditions such as addison 's disease , isolated adrenocorticotropic hormone deficiency , primary adrenal insufficiency in adrenal crisis , pheochromocytoma , thyrotoxicosis , and multiple endocrine neoplasia . it has also been described in various neurological conditions such as stroke , guillian  barre syndrome , seizures , subarachnoid bleed empty sella syndrome , and reversible posterior leukoencephalopathy syndrome . the most common cause of secondary adrenal insufficiency is a tumor of the hypothalamic - pituitary region , usually associated with panhypopituitarism caused by tumor growth or treatment with surgery or irradiation . however , takotsubo 's cardiomyopathy in a case of the pituitary tumor with secondary adrenal insufficiency has not been described to the best of our knowledge . a 48-year - old man with no known comorbid illness , presented to the emergency department with a progressive decrease in vision and headache for 2 months , vomiting for 1 day , and acute onset altered sensorium for 4 h. at admission , the patient was unresponsive with glasgow coma scale score of 6/15 ( e1m4v1 ) . he was resuscitated with intravenous ( iv ) fluids ( 2.0 l of crystalloid and 1.0 l of colloid within 1 h ) and vasopressors ( noradrenaline infusion at 0.2 mcg / kg / h ) . laboratory evaluation revealed hyponatremia ( 108 meq / l ) and hyperkalemia ( 5.5 meq / l ) . the temperature was 36c . in view of the progressive loss of vision and altered sensorium , contrast it revealed a dense sellar - suprasellar mass lesion extending into the hypothalamus , right cavernous sinus , and anteriorly under the frontal lobe of size 40 mm  23 mm . hormonal profile revealed hypocortisolism [ table 1 ] . a provisional diagnosis of hypopituitarism with secondary adrenal insufficiency in adrenal crisis was considered . hormonal profile of the patient resuscitation was continued , and central venous pressure ( cvp ) was maintained between 8 and 10 cm of h2o . after adequate fluid replacement ( cvp-12 ) , noradrenaline infusion ( 0.5 mcg / kg / h ) , and dobutamine ( 3 mcg / kg / h ) infusions were started . despite continuing active resuscitation and hormonal replacement , there was persistent hypotension , tachycardia , and worsening acidosis . a 12 lead ecg revealed sinus tachycardia with t wave inversion and st - elevation in lead 1 , 2 , avf , avl , v1-v6 , poor r wave progression in v1-v4 [ figure 1 ] . serum biomarkers showed borderline elevation ( troponin i - 0.55 ng / ml and cpk - mb -264 ) . bedside transthoracic echocardiography revealed regional wall motion abnormality involving the left anterior descending artery territory with ejection fraction ( ef ) < 40% [ figure 2 ] . an acute coronary event was suspected , and the patient was started on antiplatelets and anticoagulant ( aspirin 300 mg , clopidogrel 600 mg , and iv heparin 600 iu / h ) . electrocardiogram changes at the time of hypotension left ventricular angiogram ( a ) hyperkinetic base ( b ) akinetic apex the patient developed two episodes of ventricular tachycardia , which reverted to sinus rhythm following defibrillation . in view of the refractory hemodynamic instability , coronary angiogram showed normal coronaries and ventriculogram revealed apical ballooning of left ventricle and severe lv dysfunction with an ef of < 30% [ figure 3 ] . inotropic supports were slowly tapered over 24 h and stopped . ( a and b ) angiogram demonstrating normal coronaries beta - blocker therapy was initiated with atenolol 25 mg bd . the patient was weaned off mechanical ventilation and was continued on replacement doses of hydrocortisone and fludrocortisones . an echocardiogram was done after 7 days showed no wall motion abnormalities and complete recovery of lv function ( ef 54% ) . stress cardiomyopathy , also referred to as takotsubo 's cardiomyopathy or lv apical ballooning syndrome , is a clinical syndrome which manifests as chest pain , st segment elevation , mild elevation of cardiac enzyme , biomarker levels , and transient apical systolic lv dysfunction . approximately , 1.22.2% of admissions for acute myocardial infarction have been ultimately diagnosed to be apical ballooning syndrome due to various etiologies . emotional stress and the corresponding increase in catecholamines have been reported in many patients following takotsubo 's cardiomyopathy . proposed mechanisms for catecholamine - mediated stunning in stress cardiomyopathy include epicardial spasm , microvascular dysfunction , hyperdynamic contractility with midventricular or outflow tract obstruction , and direct effects of catecholamines on cardiomyocytes . recent reviews have proved that the apical ballooning that characterizes takotsubo 's cardiomyopathy reflects toxic high local concentrations of catecholamines and not coronary artery or microvascular disease . the elevated catecholamine levels have been shown to cause direct myocyte injury via an increase in intracellular calcium and oxygen - free radicals . the pattern of lv dysfunction may result from both myocardial cellular rupture and withdrawal of beta - adrenoceptors . another proposed mechanism is that the cardiac functional and ecg abnormalities in takotsubo cardiomyopathy might reflect activation of central neurogenic mechanisms analogous to those evoked by subarachnoid hemorrhage . myocardial histopathological findings seen in acute myocardial dysfunction associated with brain injury are similar to that of takotsubo 's cardiomyopathy . although a reversible syndrome , it can lead to complications such as left heart failure , lv intracavitary obstruction , and arrhythmias . in extreme cases , it can lead to sudden and unexpected death . patients with hypopituitarism presenting with hemodynamic instability present a diagnostic dilemma as to whether it is primarily an addisonian crisis or a myocardial event . in this case , there was an acute hemodynamic worsening , with inverted t waves and elevated cardiac biomarkers indicative of a cardiac event , soon after the initial stabilization of the addisonian crisis . although the clinical picture resembled myocardial ischemia , coronary angiography did not reveal any obstructive lesions and prompt resuscitation and supportive measures helped in the management of a potentially lethal condition . therefore , in patients with pituitary adenoma with panhypopituitarism , cardiac dysfunction due to hyper catecholaminergic states may present as potentially reversible conditions such as takotsubo 's cardiomyopathy . with more reports of neurological conditions either precipitating or presenting as takotsubo 's cardiomyopathy being reported , it is to be an important differential diagnosis in patients with neurological conditions presenting with hemodynamic instability . although the exact pathogenesis is as yet unclear , the relationship between cardiac dysfunction secondary to neurological conditions is being firmly established .