Amiodarone-induced musical hallucinations.

Musical hallucinations (MHs), a kind of auditory hallucinations (AHs), are a rarely observed phenomenon of abnormal perception of sound in the absence of an external auditory source. MHs are characterized by perception of melodies, music, or songs. AHs/MHs can be associated with hypoacusis, psychiatric or neurological diseases, intoxication and adverse reactions of different medications (e.g., propranolol, amantadine, voriconazole). A CASE REPORT: The authors present a case of a 77-year-old male with advanced heart failure, recurrent episodes of atrial fibrillations and moderate hypoacusis, who mistakenly overdosed oral amiodarone (6 pills 200 mg each daily within 3 days). After administration of 12 pills during 2 days, he started hearing music and songs not heard by others. One day later, when the number of ingested pills increased to 18, he decided to discontinue amiodarone and consulted a cardiologist; no signs of physical, ECG or laboratory deterioration were observed. MHs disappeared next day and returned only as a single episode when he tried to restart amiodarone at a dose of 1 pill daily 2 weeks later. Finally, following complete removal of the medication, he experienced no MHs whatsoever. Amiodarone is known to seldom cause neurological or mental complications; however, MHs after the drug have never been reported so far.

Tablet-based limited echocardiography at COVID-19-dedicated hospital during the pandemic in the context of takotsubo syndrome.

In the course of COVID-19 pandemic, many patients with diagnosed or suspected disease do require echocardiography. At the same time, when it comes to the echocardiographers, there is a fear of their being exposed to contamination. At COVID-19-dedicated hospital examinations are bedside, and in some patients hand-held or tablet-based echocardiography should be preferred; the echocardiographer routinely puts on a complete protective uniform. The prevalence of stress-induced takotsubo syndrome (TTS) during the Covid-19 pandemic is higher than previously reported. The authors present the images obtained using tabletbased limited echocardiography in patients with different forms of TTS. The time of the examination of patients and decontamination of the equipment was short (5-7 min and less than 2 min, respectively); the images were of fairly good quality.

Multimodality imaging of mitral annular disjunction.

Mitral valve prolapse (MVP) is diagnosed by auscultation and echocardiography in about 2-3% of the general population and takes rather a benign course. However, in some patients, ventricular arrhythmia and sudden cardiac death (SCD) occur, which is linked to mitral annular disjunction (MAD). MAD is defined as distinct separation of the mitral valve annulus-left atrial wall continuum and the basal region of the posterolateral left ventricular (LV) myocardium. MAD results in disturbed inferior-posterior LV wall and posteromedial papillary muscle stretch giving rise to local fibrosis presenting in cardiac magnetic resonance (CMR) as late gadolinium enhancement (LGE) and posing a substrate for malignant arrhythmia. Multidetector-row computed tomography (MDCT) in MAD patients is still rarely used. A CASE REPORT: Mitral valve prolapse (MVP) is diagnosed by auscultation and echocardiography in about 2-3% of the general population and takes rather a benign course. However, in some patients, ventricular arrhythmia and sudden cardiac death (SCD) occur, which is linked to mitral annular disjunction (MAD). MAD is defined as distinct separation of the mitral valve annulus-left atrial wall continuum and the basal region of the posterolateral left ventricular (LV) myocardium. MAD results in disturbed inferior-posterior LV wall and posteromedial papillary muscle stretch giving rise to local fibrosis presenting in cardiac magnetic resonance (CMR) as late gadolinium enhancement (LGE) and posing a substrate for malignant arrhythmia. Multidetector-row computed tomography (MDCT) in MAD patients is still rarely used.

Takotsubo syndrome after nimodipine-induced hypotension treated with norepinephrine in a female with subarachnoid hemorrhage.

The prevalence of takotsubo syndrome (TTS) in patients with subarachnoid hemorrhage (SAH) is much higher than in the general population. Clinical and experimental observations confirm secondary to brain damage catecholamine-mediated cardiac injury resulting in reversible left ventricular (LV) dysfunction. However, other triggers can also be involved in TTS development e.g. manipulations during surgical or endovascular treatment of a bleeding intracranial aneurysm, concomitant hyponatremia or infection, intubation, blood transfusion and pharmacologic treatment. Nimodipine is recommended in SAH to prevent cerebral arteries vasospasm but can cause hypotension, so vasopressors, e.g. norepinephrine (NE) are commonly used to reach target blood pressure. A CASE REPORT: The authors present a case of a 72-year-old woman with SAH in whom the disease began with a headache, syncope, decreased level of consciousness and vomiting; there were no cardiac symptoms at admission. Endovascular coiling of internal carotid artery aneurysm was performed. On day 2, she developed TTS presenting in echocardiography as apical ballooning; immediately before TTS onset, NE was started to treat nimodipine-induced hypotension. Despite severe heart failure (HF), the patient's neurological status did not deteriorate. HF symptoms remitted after a few days and LV function returned to normal after a week. Negative T waves in ECG which appeared at TTS onset disappeared after 50 days. At that moment no neurological deficits were observed. CONCLUSIONS: The authors underline that in SAH patients nimodipine administration should be cautious to avoid an excessive blood pressure decrease especially in view of further catecholamines use.

Asymptomatic cardiac and gallbladder involvement at initial presentation of Legionnaires' disease.

Extrapulmonary manifestations of Legionnaires' disease (LD) include, inter alia cardiac, brain, abdominal, joints and skin involvement. A CASE REPORT: The authors describe a case of a 41-year-old immunocompetent female admitted due to a high fever, chills and fatigue. She negated cough and chest or abdominal pain. Initial chest X-ray was normal. Among laboratory abnormalities were: elevation of C-reactive protein, procalcitonin, transaminases and creatinine, hyponatremia, low white blood cell and platelet count and a moderate proteinuria. ECG showed subtle ST elevation. Echocardiography revealed normal left ventricular (LV) contractility and near normal longitudinal strain, mild myocardial thickening, and a small pericardial effusion; additionally, in subcostal view, gallbladder wall thickening (GBWT) was found. Positive L. pneumophila urinary antigen test confirmed LD diagnosis. Control Xray and CT showed development of pleural effusion and bilateral pulmonary infiltrations. Clinical and radiologic improvement of the disease was achieved with ciprofloxacin therapy started from admission. ECG abnormalities persisted for only 5 days, GBWT resolved after 9 days, pericardial effusion disappeared after 10 days; normalization of LV thickness and an increase in longitudinal strain was found within 2 weeks. However, cardiac magnetic resonance (CMR) performed after a month revealed focal midmyocardial and linear subepicardial late gadolinium enhancement (LGE). CONCLUSIONS: The authors underline the fact that being aware of extrapulmonary LD, also silent, may allow to diagnose the disease, especially when pulmonary involvement is initially absent.

Transient left ventricular hypertrophy in a 30-year-old female with chronic emotional stress and depression treated with venlafaxine.

Transient left ventricular hypertrophy or thickening (TLVH/T) is a phenomenon rarely observed in some patients with myocarditis and stress-induced takotsubo syndrome (TTS). Initial presentation on echocardiography can mimic hypertrophic cardiomyopathy (HCM), sometimes with a decreased ejection fraction (EF). A CASE REPORT: The authors describe TLVH/T in a 30-year-old female with a history of chronic emotional stress and depression treated with venlafaxine (75 mg twice a day). She suffered from spinocerebellar ataxia (SCA) and, because of a family conflict, was living alone with a daughter who was diagnosed with maple syrup urine disease (MSUD). At admission, she presented with advanced heart failure with pulmonary congestion, moderately elevated blood pressure, ECG signs of LV hypertrophy (with negative T waves in leads: I-III, aVF, V4- 6) and with mild troponin I and high BNP elevation. Echocardiography revealed hypertrophy of the LV myocardium, systolic dysfunction and a small pericardial effusion. She denied any chest pain; there were no clinical features of infection or connective tissue disorder. Genetic nature of the patient's SCA and of her daughter's MSUD gave rise to a suspicion that she had coexistent HCM. She received therapy with ramipril, carvedilol and diuretics; venlafaxine was not discontinued. Cardiac magnetic resonance (CMR) performed a month later showed LV thickening to be a little smaller, absence of late gadolinium enhancement and an improvement of EF; T2-weighted images were not studied. Unexpectedly, after several months, LV hypertrophy disappeared in subsequent ECG, echocardiography and CMR; simultaneously, EF as well as regional and longitudinal strain returned to normal values.

Severe transient left ventricular dysfunction in a patient with Legionella pneumophila pneumonia.

Legionella pneumophila infection (legionellosis) usually presents as a multisystemic disease, predominantly affecting the lungs (Legionnaires' disease - LD). Immunodeficiency, chemotherapy or chronic steroids use increase the risk of developing LD. Extrapulmonary manifestations of LD include cardiac complications: myocarditis, pericarditis or endocarditis. A CASE REPORT: The authors describe a case of a 51-year-old female with a history of cryoglobulinemic vasculitis, Sjögren syndrome and chronic lymphocytic leukemia who was admitted due to a high fever, fatigue, tachycardia, dyspnea and cough. Chest X-ray and CT showed bilateral pulmonary infiltrations and pleural effusion. LD was diagnosed on positive L. pneumophila urinary antigen test. Echocardiography revealed severe left ventricular (LV) dysfunction with substantially decreased ejection fraction and global longitudinal strain (GLS), with a pattern resembling reverse takotsubo syndrome (rTTS). The coronary arteries in non-invasive coronary angiography were normal. During therapy with levofloxacin and intravenous immunoglobulins as well as with carvedilol, ramipril and diuretics, gradual clinical improvement with complete normalization of LV function was observed within 5 weeks. Cardiac magnetic resonance (CMR) performed on day 35 revealed only small intramural foci of late gadolinium enhancement (LGE) with localization not corresponding to the most decreased regional longitudinal strain in the initial echocardiographic examination. The authors suggest that the mechanism of transient LV dysfunction in the case presented may have been of complex nature, including LD myocarditis and stress-induced cardiomyopathy (with the prevalence of the latter) which has not so far been reported in the literature.

Daily longitudinal strain evaluation for left ventricular function monitoring in a 65-year-old female with reverse syndrome takotsubo and multiple triggering factors.

Among patients with takotsubo syndrome (TTS), reverse TTS (rTTS) constitutes 1-23% of all cases reported in the literature. The highest prevalence of rTTS is observed in intracranial hemorrhage, pheochromocytoma and severe infections. A CASE REPORT: The authors describe a case of a 65-year-old female with advanced multiple myeloma in whom rTTS was recognized on admission due to streptococcal sepsis. Other possible triggering factors included: anemia, blood transfusion, transient acute renal failure with electrolyte imbalance. ECG showed ST-segment depression in precordial leads and echocardiography revealed severe left ventricular (LV) dysfunction with apical sparing and with decreased ejection fraction (EF) and global longitudinal strain (GLS): 30 % and -10 %, respectively. Daily echocardiography showed gradual normalization of GLS as well as of regional longitudinal strain (RLS) within 8 days. The authors confirm the distinctness of rTTS including clinical, ECG, echocardiographic and laboratory findings and suggest the usefulness of daily longitudinal strain evaluation for LV function recovery monitoring.

Takotsubo syndrome in a patient with adrenal insufficiency, severe hyponatremia and coexistent coronary artery disease.

Some endocrine disorders, including primary and secondary adrenal insufficiency (AI), predispose to takotsubo syndrome (TTS). Hyponatremia is a frequent feature seen in adrenal crisis; however, TTS cases preceded by low serum sodium associated with other diseases are also reported. A CASE REPORT: The authors describe a case of a 72-year-old female with primary AI (Addison's disease) after adrenalectomy due to adrenal hypertrophy she underwent in childhood. Before admission, she missed a few doses of replacement therapy with prednisone and fludrocortisone. On admission, she presented with hypotension, severe heart failure (HF) and hyponatremia. Negative T-waves in ECG and left ventricular (LV) apical ballooning in echocardiography were suggestive of TTS. Restarted replacement therapy and symptomatic HF treatment resulted in gradual LV function normalization within 6 days. Cardiac magnetic resonance (CMR) performed after 4 weeks was normal and did not reveal any late gadolinium enhancement (LGE). However, elective coronary angiography made a month later showed critical stenosis of the left anterior descending coronary artery which was treated with coronary angioplasty. The authors suggest that each patient with adrenal crisis as well as with severe hyponatremia should be evaluated by echocardiography. The case presented confirms a possible coexistence of TTS and obstructive coronary artery disease.

Takotsubo syndrome following mitral valve replacement and left anterior descending coronary artery bypass grafting.

Takotsubo syndrome (TTS) is rarely diagnosed following valvular and nonvalvular cardiac surgery. Only several such cases, including 12 after mitral valve replacement (MVR) or plasty (MVP) and 2 after coronary artery bypass grafting (CABG) have been reported so far. A CASE REPORT: The authors describe a case of a 75-year-old female in whom TTS occurred on the first postoperative day after elective combined surgery: MVR (with bioprosthesis) and CABG (of the left anterior descending coronary artery). Echocardiography revealed left ventricular (LV) dysfunction in the form of apical ballooning with markedly decreased ejection fraction (EF) and global longitudinal strain (GLS): 28 % and -9.3 %, respectively; there were no signs of prosthesis dysfunction. Due to circulatory and concomitant respiratory failure, she was transferred to the intensive care unit; however, an intra-aortic balloon pump was not necessary. Normalization of LV function (EF 60%, GLS -18.5%) was observed after 2 weeks. The authors compare the clinical data of the case presented with those of the remaining 14 TTS patients after MVR, MVP or CABG described in the literature and emphasize the coexistence of multiple triggering factors (e.g. additional procedures, catecholamines use, protamine use, pleural or pericardial drainage, blood transfusion, rapid heart rate). The authors suggest that TTS should be routinely included in differential diagnosis of post-cardiac surgery heart failure decompensation.

Takotsubo syndrome triggered by emotional and physical stress due to coincidental immobilization resembling the experimental model of the disease - a case report.

The term takotsubo syndrome (TTS) is derived from a comparison of left ventricular (LV) appearance in its apical form to the shape of the pot which is a trap used for octopus catching. In the classical animal model on rats, its occurrence can be triggered by experimental immobilization (IMO). Former observations of capture myopathy, seen in animals after extreme exertion, showed coexistence of rhabdomyolysis related to skeletal muscle injury and myocardial damage. The authors describe a case of a 66-year-old obese female in whom TTS was triggered by an uncommonly stressful event when she had been trapped in the bathtub for several hours. The woman lives alone and has impaired functionality due to degenerative disease of the spine and hips. On this unlucky day, she decided to have a bath after which she was unable to get out of the bathtub despite repeated efforts. She was very frustrated and helpless having to spend all the evening and night in that cul-de-sac-like situation. She was rescued in the morning by neighbors and firemen who transferred her to hospital. On admission she was exhausted and suffering from dyspnea, she negated any chest pain; there were bloody abrasions on her elbows. Due to negative T waves in ECG and elevated troponin I, echocardiography was performed which revealed LV apical ballooning. The high level of creatine phosphokinase (CPK) was suggestive of rhabdomyolysis. Following heart failure therapy, the patient's clinical state, as well as echocardiographic parameters, improved gradually. Normalization of LV function and CPK values was observed after 11 days.

Takotsubo cardiomyopathy triggered by influenza B.

Influenza is associated with a high prevalence of cardiac complications, including myocarditis and exacerbation of ischemic heart disease or heart failure (HF). However, only four cases of stress-induced takotsubo cardiomyopathy (TC), all of them triggered by virus A influenza, have been reported so far. Another two TC cases after anti-influenza vaccination are also available in the literature. The authors describe a new case of TC, this time provoked by influenza B. An 89-year-old female with a history of hypertension and chronic obstructive pulmonary disease (COPD) was admitted due to a fever (39oC), muscle aches and cough. Pneumonia was excluded in chest X-ray while the test for influenza confirmed virus B infection, so she was given oseltamivir. On the second day of hospitalization, she developed severe HF. ECG showed new negative T waves in inferior and anterolateral leads coexisting with a moderate troponin I and marked brain natriuretic peptide release, while echocardiography revealed left ventricular (LV) apical ballooning with decreased ejection fraction (EF 24%) and global longitudinal strain (GLS -8.1%). Symptomatic treatment of HF was initiated. The symptoms of influenza resolved after 5 days. LV function began to improve after 4 days and became normal after 6 days (EF 58%, GLS -18.1%). Despite an advanced age and the coexisting disorders (COPD, mild cognitive impairment, possible neoplastic disease), the patient was discharged in stable clinical condition on day 10. The authors conclude that in the evaluation of cardiac complications of influenza, TC should be taken into account.

Apixaban in left ventricular thrombi treatment - a report of seven cases.

Treatment of intracardiac thrombi (ICTs) with direct-acting oral anticoagulants (DOACs) constitutes a new challenge for this group of medications. Left ventricular thrombi (LVTs) occur mainly in patients with severe left ventricular dysfunction. Advanced heart failure is characterized by a high prevalence of chronic kidney disease (CKD). Apixaban has the best renal profile among all DOACs. The authors describe a group of 7 patients with LVTs treated with apixaban; 6 of them had CKD. LVTs were screened and monitored during therapy using a sector, 3-dimensional and high frequency linear probes; the latter to exclusively assess the left ventricular apex. Examination was performed every day during the first 2 weeks, then 2-3 times a week until LVTs disappearance, then every month; transesophageal assessment was done initially and repeated when necessary. Patients' mean age was 65 years. The underlying disease was post-myocardial left ventricular dysfunction (3), dilated cardiomyopathy (3) and heart failure of unknown etiology (1).Three patients had more than one LVT. Also, three had other ICTs, one - in the right ventricle, two - in the left atrial appendage. Three patients used apixaban in a dose of 5 mg twice daily, two - 2.5 mg twice a day, two - in an increasing dose. In all patients, gradual diminishing of LVTs was observed, no complications of apixaban therapy were noted. The time needed for LVTs disappearance was between 7 and 28 days (mean: 17 days).

Takotsubo cardiomyopathy triggered by profound hypoglycemia in a 39-year-old female with anorexia nervosa: strain monitoring of left ventricle function recovery.

Anorexia nervosa (AN) is characterized by very low body mass index (BMI), related to obsessive fear of gaining weight, resulting in food restriction. In AN various cardiac complications may occur: hypotension, bradycardia, life-threatening ventricular arrhythmias, pericardial effusion, reduction of left ventricular mass and impairment of its function. Stress-induced takotsubo cardiomyopathy (TC) is reported rarely since sympathetic activity in AN patients is lower than in healthy individuals. Different mechanisms are suggested to be involved in TC pathogenesis, including low estrogens levels or dyselectrolitemia, but hypoglycemia, which results in sympathetic stimulation, seems to be more important. A CASE REPORT: The authors describe a case of a 39-year-old female with so far untreated advanced AN, admitted to hospital due to profound hypoglycemia (17 mg/dl), cachexia (BMI 11) and with heart failure. Echocardiography revealed severe left ventricular (LV) dysfunction in the form of apical TC with markedly decreased ejection fraction (28%) and global longitudinal strain (-10.2%). She received therapy focused on metabolic disturbances correction. Daily echocardiography was performed to follow LV function recovery, including longitudinal strain normalization, which was observed after two weeks. TC should be considered as a potential AN complication, but it may be triggered by hypoglycemia of any etiology. Longitudinal strain assessment is a convenient and accurate mode of LV function monitoring in TC patients.

Takotsubo cardiomyopathy in a young male with lung cancer and neoplastic embolization of the coronary microcirculation.

The associations between stress-induced takotsubo cardiomyopathy (TC) and cancer or its therapy have been studied with increasing interest in recent years. Different mechanisms of TC development in neoplastic disease are suggested, including a decreased threshold for stress stimuli or aggravated heart adrenoreceptors sensitivity. The action of cytokines and reactive oxygen species on the myocardium, on the epicardial arteries as well as on the coronary microcirculation is also taken into consideration. The authors describe a case of a 30-year-old male with lung cancer, after immunotherapy with checkpoint inhibitors followed by two lines of chemotherapy and after pericardial and pleural drainage. He was admitted to hospital due to severe heart failure (HF) with echocardiographic features of apical TC. During symptomatic treatment of HF his state temporarily improved and left ventricular function returned to normal. Unfortunately, a few days later, he died. The autopsy revealed histological features of TC (contraction band necrosis), cardiac infiltration by cancer and the presence of cancer cells in the coronary microcirculation, which was not previously reported in TC patients. The authors emphasize that disseminated neoplastic embolization of the coronary microcirculation may be important in TC pathogenesis in some cancer patients.

Lactobacillus gasseri endocarditis on the aortic valve bioprosthesis - a case report.

Lactobacillus is a genus of Gram-positive, facultative anaerobic/ microaerophilic, rod-shaped bacteria. Lactobacilli constitute a significant component of the human microbiota in the oral cavity, gastrointestinal tract and female urogenital tract. They are also widely used as probiotics. Rarely, especially in patients with impaired immunity or with structural heart disease, do Lactobacilli become the pathogen responsible for serious infections, e.g. infective endocarditis (IE). CASE REPORT: The authors describe a case of an 80-year-old female with a past history of aortic valve replacement, mitral annuloplasty and pacemaker implantation admitted to hospital due to weakening, subfebrile state and chills. In transesophageal echocardiography vegetations on the aortic valve bioprosthesis were found, while pacemaker electrodes and mitral annulus were not involved in the endocarditis process. Bacteriological work-up revealed growth of L. gasseri. The patient was successfully treated with amoxicillin/clavulanate acid (six weeks) and with gentamycin (two weeks). No recurrence of the disease was observed during a six-month posthospital follow-up. Among different species of Lactobacillus, L. gasseri has not been reported as an IE pathogen so far. Lack of unequivocal data as to whether using probiotics may be responsible for infections, including IE, in patients with predisposing conditions.