Rita, 32 years old lady brought to emergency of tertiary care hospital on Sunday morning. She was not responding to verbal commands, peripheral pulses were not palpable, RBS was 32 mg/dl. Casualty medical officer ordered to give 25% dextrose iv bolus and bring emergency trolley nearby. Carotid pulse was there so CPR not initiated.

I, as endocrinology resident attending another case nearby alerted after hearing low RBS and rushed to that patient. She was in coma, GCS-E1V1M1, only carotid pulse was palpable. CMO and nursing staff were standby for resuscitation. With my one hand palpating carotid artery I asked only two questions to her husband that brought me to most probable diagnosis for her hypoglycemia and low BP. She was not having any signs of cardiac, hepatic or renal failure. Sepsis was also unlikely due to afebrile presentation in a young patient.

Is she menstruating?

No

Did she breastfed your last borne child?

No.

I ordered to give Hydrocortisone 100mg iv stat immediately and to rush Normal saline. After 5 min peripheral pulses appeared. Patient admitted and shifted to ICU.

Now I took proper detailed history. She was absolutely fine till she delivered a baby boy 8 years back which was normal hospital delivery, no excess bleeding, otherwise uncomplicated. She had poor breast milk flow, when asked, pediatrician replied this happens in some cases and started child on formula milk. Her menstruation not restarted even after 2 years of delivery and till date. Moreover she always had feeling of nausea and sometimes vomiting, dizziness, falls. Her face looked plethoric and dry.

She consulted multiple times to family doctor and general physicians and diagnosed to have ACID PEPTIC DISEASE so PPI and antiemetic medications prescribed. Over the time her complaints were severe and she also loose weight. Primary care physician suspected abdominal tuberculosis and investigated. There was mesenteric lymph nodes on ultrasound and raised ESR. TB gold test was positive (which is not confirmatory test). She started on AKT (Rifampicin, Isoniazid, Ethambutol and Pyrazinamide). 3rd day after commencing Rifampicin she was brought to casualty.

On investigation there was hyponatremia, low ft3, low ft4 and low TSH, low FSH, low LH, normal prolactin level, empty Sella on MRI all suggesting panhypopitutarism. This is a case of PANHYPOPITUTARISM survived somehow 8 years with gradual deteriorating general condition. Rifampicin is strong CYP3A4 inducer so she acutely worsened after Rifampicin.