potential incriminators are growth hormone , thyroid hormone , and gonadal hormone deficiency . growth hormone deficiency has been associated with endothelial dysfunction [ as evidenced by higher levels of plasminogen activator inhibitor - i levels ( pro - coagulant ) , loss of circulating cd34 + cells ] , increased total cholesterol , low - density lipoprotein ( ldl ) cholesterol , increased body fat ( truncal and waist  hip ratio ) , decreased lean body mass and increased risk of hypertension . both central hypothyroidism and hypogonadism has also been associated with increased ( serum total and ldl cholesterol , homocysteine , ( c - reactive protein ) crp ) and impaired endothelial - dependent vasodilatation and insulin resistance . haffner et al . showed that the incidence of fatal and nonfatal myocardial infarction to be 3.5/100 person - years in nondiabetics as compared with 20.2/100 person - years in patients with t2 dm . a 62-year - old male patient coming from the interiors of maharashtra ( kolhapur ) , india , a nonsmoker , nonethanolic , on the background history of diabetes mellitus since the past 10 years , presented with sudden onset severe headache , right sided ptosis , for which he got admitted in a local hospital . imaging of the brain showed pituitary macroadenoma . within a few hours of admission he developed features suggestive of acute left ventricular failure secondary to acute coronary syndrome ( non - st - elevation myocardial infarction associated with elevated serum troponin t , regional wall abnormalities of mid and basal septum and apical and lateral wall of left ventricle on 2d - echocardiography . he discharged himself and was referred to our endocrine team by the cardiologist . on examination his observations read as follows : blood pressure 120/80 mmhg in right arm without any postural fall , pulse 84/bpm , elevated jugular venous pressure . baseline biochemical tests were normal except for an elevated creatine phosphokinase - mb 115 ( 4 - 36 iu / l ) and troponin - t 21 mcg / l ( 00.1 ) . follicular stimulating hormone ( fsh ) 0.79 m iu / ml ( 0.95 - 11.95 ) , luteinizing hormone ( lh ) 0.43 miu / ml ( 0.57 - 12.07 ) , total testosterone 0.88 ng / ml ( 1.56 - 5.63 ) , prolactin 1.14 ng / ml ( 3.46 - 19.4 ) , t3 53.49 pg / ml ( 58 - 159 ) , t4 6.74 ng / ml ( 4.87 - 11.72 ) , thyrotropin stimulating hormone ( tsh ) 0.08 miu / ml ( 0.2 - 6 ) , adrenocorticotropic hormone 68 pg / ml ( 10 - 100 ) , cortisol 17.4 mcg / dl ( 3.729.4 ) [ tests done while on hydrocortisone treatment ] , insulin like growth factor- 1 ( igf)-1 55.5 ng / ml ( 75 - 212 ) , with a serum sodium of 139 meq / l . 2d echo showed a reduced ejection fraction of 35% with septal and left ventricular apical and lateral regional wall abnormalities . dexa densitometry revealed severe osteoporosis at the level of both hip ( t - score magnetic resonance imaging ( mri ) pituitary [ figure 1a and b ] showed a sellar mass ( 2.2  1.3 cm in size ) causing compression of optic chiasma . ( a ) mri showing a sellar mass ( 2.2  1.3 cm in size ) causing compression of optic chiasma , ( b ) mri showing sellar mass compressing optic chiasma and invading cavernous sinus a coronary angiogram showed totally occluded right coronary artery proximally , 90% proximal stenosis of left anterior descending artery with heavy calcification and obtuse marginal 1 and 2 showing > 85% stenosis . a coronary artery bypass surgery was planned , which was undertaken successfully under appropriate steroid and thyroid hormone cover . after 4 weeks , he had complete resolution of his right sided 3 cranial nerve palsy . pituitary apoplexy refers to a clinical syndrome characterized by sudden onset headache , vomiting , visual impairment , and decreased consciousness caused by hemorrhage and/or infarction of the pituitary gland , which usually occurs in patients with preexisting pituitary adenomas and prolactinomas evolving over a period of hours or days . patients with hypopituitarism are subject to a significant increase in all cause mortality ( standardized mortality ratio being 2.06 for males and 2.8 for female ) and mortality from vascular disease ( standardized mortality ratio 1.4 for males and 1.7 for females ) . on the background of diabetes mellitus this cardiovascular mortality is amplified . the case described brings to light the need for an appropriate cardiovascular evaluation in patients with hypopituitarism especially if they have a background history of t2 dm . current practice in patients presenting with hypopituitarism is to provide appropriate hormonal replacement and follow - up is focused only on the pituitary gland . there may be an argument for aggressive cardiac evaluation and treatment in patients with t2 dm associated with hypopituitarism . this is the first case of pituitary apoplexy presenting as myocardial infarction to be reported from india .
we describe a male patient who presented with sudden onset severe headache and right sided ptosis that was diagnosed to be secondary to pituitary apoplexy on the background of diabetes mellitus . 
 this was complicated by left ventricular failure and acute coronary syndrome . 
 the case highlights the importance of considering hypocortisolism / hypopituitarism as an important and rare precipitant of an acute coronary event as occurred in the case .