A 55 year-old man was brought to the emergency room because of hypotension, fatigue, fever and pain in the left shoulder. The blood glucose, sodium, potassium levels were normal. ECG showed 65/min sinus rhythm with negative T waves in the precordial leads. Blood pressure was 70/50 mmHg. Suddenly torsade des pointes occurred, which was converted to sinus rhythm with 300 mg amiodarone. Coronarography showed no significant stenosis on epicardial coronaries. During the intervention supraventricular tacyhcardia occurred for 30 s, and disappeared after 150 mg amiodarone, ECGs showed no PQ prolongation, 76/min sinus rhythm and diffuse T-wave depression. Echocardiography found EF 38%, anterior, inferior, septal akinesis. On the 4th and 7th day of observation 35/min bradycardia occurred with junctional and ventricular extrasystole requiring defibrillation with 200 J. TSH measurement suggested hypothyroidism (TSH: 13.89 mIU/l), severe hypocalcaemia suggested hypoparathyroidism. Serum total calcium level was: 1.82 mmol/l, PTH: 1.5 pmol/l. Low serum hydrocortisone value revealed adrenal insufficiency. As the suggested diagnosis was polyglandular autoimmune syndrome we performed autoimmune screening and found anti transglutaminase antibodies. However, further autoimmune screening showed no sign for other autoimmune disesases. Gluten-free diet, hydrocortisone, L-thyroxine, calcium, vitamin D3, and testosterone supplementation started, ICD was implanted. Torsade never occurred again. Last results showed normal Ca, TSH, fT3, fT4 values, mildly lower testosterone, suppressed ACTH and mildly elevated cortisol levels.
Conclusion: We found gluten-enteropathy caused persistent polyglandular endocrine failure leading to torsade de pointes tachycardia requiring several reanimation and ICD implantation without having autoimmune origin.
27 Apr - 01 May 2013
European Society of Endocrinology