Not All Shocks Are Created Equal: Refractory Cardiogenic Shock Unmasking Panhypopituitarism Following Acute Coronary Syndrome

BACKGROUND: Adrenal insufficiency is an uncommon but reversible cause of shock that may coexist with cardiogenic shock in acute coronary syndrome and be overlooked once significant coronary artery disease is identified.

CASE SUMMARY: A 59-year-old man presented with non-ST-segment elevation myocardial infarction complicated by cardiogenic shock. Despite successful percutaneous coronary intervention to critical left anterior descending and right coronary artery lesions, he remained in refractory shock requiring escalating inotropic support. Retrospective recognition of secondary hypothyroidism and a bitemporal visual field defect raised suspicion of pituitary insufficiency. Empiric hydrocortisone resulted in rapid hemodynamic recovery. Subsequent evaluation confirmed panhypopituitarism, whereas magnetic resonance imaging demonstrated a cystic sellar lesion compressing the pituitary gland.

DISCUSSION: Secondary adrenal insufficiency should be considered when shock persists despite successful revascularization and cardiac recovery.

TAKE-HOME MESSAGE: Early glucocorticoid replacement may be lifesaving and should not await hormonal confirmation when adrenal crisis is suspected.