Naphazoline intoxication with transient QT prolongation and acute myocardial injury.

A 27-year-old Japanese woman with a history of depression and an eating disorder presented to our emergency department with a chief complaint of generalized weakness. Electrocardiography showed prominent QT prolongation with multiple ventricular contractions. Chest X-ray plain computed tomography revealed pulmonary edema. Echocardiography showed decreased left ventricular systolic function. Suspecting acute myocarditis, we performed a myocardial biopsy from the right ventricular septum. The biopsy histology revealed extensive myocardial fibrosis and a very mild inflammatory cell infiltrate. In an additional detailed medical interview, the patient admitted that she had consumed three bottles of a first-aid liquid containing naphazoline approximately ~12 h before her presentation, in a suicide attempt. Her QTc and left ventricular ejection fraction improved during hospitalization. Learning objective: Acute drug intoxication can cause QT prolongation and ventricular arrhythmias, cardiomyopathy, and pulmonary edema. When acute QT prolongation, myocardial damage, and pulmonary edema are seen (suggesting acute myocarditis), naphazoline intoxication should be investigated in the differential diagnosis.

An ophthalmologist with myocardial bridging developed takotsubo cardiomyopathy while operating; A case report and literature review.

Key Clinical Message: Healthcare workers are prone to very high level of physical as well as emotional stress that lead to devastating health-related consequences which include but not limited to cardiovascular events that may lead to death. Recognizing the risk of Takotsubo Cardiomyopathy among healthcare worker is the main aim of this report. Abstract: Takotsubo Cardiomyopathy (TC) is a reversible left ventricular wall motion abnormality that could not be explained by coronary artery disease and is typically precipitated by either emotional or physical stress. There is no sufficient data regarding the incidence of TC among healthcare workers and people with myocardial bridging. Here we are describing a case of an ophthalmologist with myocardial bridging who developed TC while in the operation theater.

Glucocorticoid-Induced Cardiomyopathy Caused by Uncontrollable Asthma.

Hypercortisolism is a risk factor for adverse cardiovascular and cerebrovascular outcomes, including hypertension, hyperglycemia, and dyslipidemia. It has been suggested that cardiovascular risk increases with increasing steroid use in patients taking oral steroids as immunosuppressive drugs. Cardiomyopathy is often reported to occur concomitantly in patients with Cushing's syndrome. Reports of cases of long-term high-dose glucocorticoid ingestion and concomitant cardiomyopathy are rare. We report a case of cardiomyopathy in a 63-year-old Japanese man. He had refractory bronchial asthma and had been on prednisolone ≥15 mg/day equivalent for >20 years. Echocardiography showed severe left ventricular dilatation, left ventricular systolic dysfunction, and mitral regurgitation. Since other secondary cardiomyopathies were excluded, a diagnosis of glucocorticoid cardiomyopathy was made, cardioprotective drugs were introduced, and the steroid dose was reduced during hospitalization. Four months after the patient's discharge, echocardiography showed normalization of left ventricular systolic function.

Takotsubo Cardiomyopathy: A Possible Rare Complication of Guillain-Barré Syndrome.

Dysautonomia is a common and severe complication of Guillain-Barré syndrome (GBS), which may manifest as cardiac arrhythmias, labile blood pressure, diaphoresis, and changes in gastrointestinal motility. Takotsubo cardiomyopathy (TCM) is a life-threatening manifestation of dysautonomia in patients with GBS, which is not widely underlined in the literature. The association between GBS and TCM has been well-documented in previous studies; however, there are few reported cases with GBS who developed TCM following their diagnosis with GBS. In this case report, we will discuss our experience treating a 59-year-old female patient who became hemodynamically unstable while recovering from an acute GBS infection. She was diagnosed with TCM after undergoing an echocardiogram and coronary angiogram ruling out thrombotic or obstructive coronary disease and myocarditis.

A Rare Case Report of Flecainide-Induced Left Bundle Branch Block (LBBB) and Transient Cardiomyopathy.

Flecainide is an antiarrhythmic agent that has been reported to have numerous cardiotoxic effects, including the development of arrhythmias and the reduction of left ventricular ejection fraction (LVEF). However, it is not commonly reported as a cause for left bundle branch block and cardiomyopathy. In this case report, we present the case of a 67-year-old female patient who developed transient cardiomyopathy and left bundle branch block (LBBB) secondary to flecainide therapy. The patient's condition improved upon cessation of flecainide.

Tachycardia-Induced Cardiomyopathy in a Young Adult: The Significance of Early Diagnosis and Treatment.

Tachycardia-induced cardiomyopathy (TIC) is gradually gaining the attention it deserves as one of the most common causes of reversible cardiomyopathy. Although TIC appears common, there has been limited data, especially among young adults. Patients with tachycardia and left ventricular dysfunction should be suspected of having TIC, with or without established etiology of heart failure, because TIC can develop by itself or contribute to cardiac dysfunction. We present a case of a previously healthy 31-year-old woman with persistent nausea and vomiting, poor oral intake, fatigue, and persistent palpitations. Vital signs at presentation were significant for tachycardia of 124 beats per minute, which she reported was similar to her baseline heart rate of 120s per minute. There were no apparent signs of volume overload at the presentation. Labs were significant for microcytic anemia with hemoglobin/hematocrit of 10.1/34.4 g/dL, and mean corpuscular volume was low at 69.4 fL; other labs were unremarkable. Transthoracic echocardiography obtained at admission was significant for mild global left ventricular hypokinesis, systolic dysfunction with an estimated left ventricular ejection fraction of 45-50%, and mild tricuspid regurgitation. Persistent tachycardia was suggested as the primary cause of cardiac dysfunction. The patient was subsequently started on guideline-directed medical therapy, including beta blockers, angiotensin-converting enzyme inhibitors, and spironolactone, with eventual normalization of the heart rate. Anemia too was also treated. Follow-up transthoracic echocardiography done four weeks after was notable for significant interval improvement in left ventricular ejection fraction of 55-60%, with a heart rate of 82 beats per minute. The case illustrates the need for early identification of TIC regardless of the patient's age. It is essential that physicians consider it in the differential diagnosis of new-onset heart failure because prompt treatment leads to the resolution of symptoms and improvement of ventricular function.

Tachycardia-Induced Cardiomyopathy in a Young Healthy Patient: A Case Report.

Tachycardia-induced cardiomyopathy (TIC) can result in both systolic and/or diastolic ventricular dysfunction as a result of the prolonged fast heart rate which is reversible upon controlling the fast heart rate or arrhythmia. The exact heart rate that can lead to this is not clear, however, a heart rate > 100 in general needs attention. Tachycardia-induced cardiomyopathy is a well-established cause of left ventricular dysfunction which usually happens due to an increased atrial or ventricular rate. The incidence of TIC is very low although the exact incidence is unclear. It should be considered in all patients with dilated cardiomyopathy or those with no obvious explanation for dilated cardiomyopathy and in presence of tachycardia or atrial fibrillation with a rapid ventricular response. Tachycardia-induced cardiomyopathy has also been labeled as arrhythmia-induced cardiomyopathy lately. We present a case of a 50-year-old patient who presented with a fever of 39oC, feeling generally unwell, had a sore throat, and collapsed at home after several episodes of vomiting after two days of intense exercise. He was diagnosed with suspected tonsillitis and was treated with co-amoxiclav. He was exercising over 10 hours weekly for the last two months in the gym for the Ironman triathlon in London. An echocardiogram showed severe left ventricular systolic dysfunction (LVSD) with a left ventricular ejection fraction (LVEF) of 25%. An electrocardiogram showed sinus tachycardia with a right bundle branch block (RBBB). Cardiac magnetic resonance imaging (CMR) showed normal biventricular function with an ejection fraction (EF) of 71% four months later. The patient was diagnosed with tachycardia-induced cardiomyopathy. This case is unique as the patient presented with transient severe LVSD after training for the ironman triathlon and spontaneous recovery.

A Broken Heart After Witnessing a Dying Heart: A Case of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy is a form of non-ischemic cardiomyopathy characterized by transient systolic dysfunction. The prevalence of Takotsubo cardiomyopathy has been estimated to be about 2% overall but about 10% amongst women presenting with clinical manifestations of acute coronary syndrome. The overall mechanism of the disease still remains unclear. However, treatment of Takotsubo cardiomyopathy appears to be similar to congestive heart failure (CHF) medical management. This case highlights the classic presentation exhibited very similar to acute coronary syndrome and diagnostic criteria for Takotsubo (stress-induced) cardiomyopathy.

Beri-Beri and Wernicke Encephalopathy in a Thirty-Year-Old Male.

A 30-year-old Turkish male was found lethargic and surrounded by vomit. At the hospital, severe hypernatremic dehydration and acute kidney failure were evident. His conscious level improved with fluid resuscitation. A differential diagnosis of altered mental status was considered. A complete clinical triad of Wernicke encephalopathy (WE), supported by MRI findings, was compatible with thiamine deficiency. Previous bariatric surgery was later confirmed. Despite no clinical signs of heart failure, a high level of NT-proBNP (N-terminal prohormone brain natriuretic peptide) and a dilated, hypokinetic myocardiopathy detected on the echocardiogram led us to assume beri-beri heart disease. High-dose intravenous thiamine, ACE (angiotensin conversing enzyme) inhibitors, beta-blockers, and physical therapy were initiated with remarkable improvement in his clinical condition.

Atypical Takotsubo Cardiomyopathy Presentation in an Adult Patient.

Takotsubo cardiomyopathy (TSC) is a transient cardiac condition brought on by physical and emotional distress causing left ventricular akinesis. Typically, patients are older females that present with substernal chest pain radiating to the left arm, presenting similarly to acute coronary syndrome. In addition, the elevated troponins and EKG changes such as ST elevations and T wave inversions seen in acute coronary syndrome may also be appreciated in TSC. While there have been many reports of TSC presenting in a similar manner to acute coronary syndrome, this case report will describe an atypical presentation of Takotsubo cardiomyopathy. The patient we are presenting is an African American middle-aged female who presented to the emergency department with a four-day history of non-bilious, non-bloody vomiting. Chief complaint denied any chest pain, shortness of breath, or recent physical and emotional stressors. Her past medical history was significant for Chronic Obstructive Pulmonary Disease Gold Criteria 2, controlled Hypertension, and Human Immunodeficiency Virus for which she is on antiretroviral therapy. Her hospital course was complicated by shortness of breath beginning on day two as well as elevated troponin levels and global T wave inversions on EKG. Patient underwent cardiac catheterization, which revealed left ventricular akinesis with an ejection fraction of <30%. Catherization also revealed no obstructive coronary artery disease, thus the diagnosis of Takotsubo cardiomyopathy was made.

A Case of Severe Dilated Cardiomyopathy and Hyperthyroidism.

Hyperthyroidism often leads to heart failure when left untreated, specifically high output heart failure and left ventricular (LV) hypertrophy. A very minimal portion of those develop severe LV dysfunction. We report a case of a 65-year-old male who presented with signs and symptoms of heart failure and was found to have hyperthyroidism, severe systolic dysfunction, and severe dilated cardiomyopathy. The patient is a 65-year-old African American male with a history of hypertension (HTN) who presented with complaints of dyspnea on exertion and bilateral lower limb edema of one-week duration. A review of systems revealed paroxysmal nocturnal dyspnea, orthopnea, palpitations, fatigue, and weight loss. Physical exam showed tachycardia but otherwise no exophthalmos, no thyromegaly, no thyroid nodules, clear lungs, normal heart sounds, regular heart rhythm, normal reflexes, and 2+ edema of bilateral lower extremities up to the knees. Labs showed elevated B-natriuretic peptide, severely suppressed thyroid-stimulating hormone, elevated free triiodothyronine (FT3), and free thyroxine (FT4). Electrocardiogram (EKG) revealed sinus tachycardia, incomplete left bundle branch block, and non-specific T wave abnormality. Echocardiography revealed abnormal (LV) structure and function, with moderate to severe dilatation without LV hypertrophy, severe LV systolic dysfunction with ejection fraction (EF) 30-35%, and an abnormal LV diastolic function. The patient was managed with diuresis for acute onset heart failure and with beta-blocker and methimazole for symptomatic hyperthyroidism. Thyroid assessment is an important step in evaluating any patient with suspected heart failure. This case highlights the balance that should exist between treating hyperthyroidism symptoms and managing disease states such as acute heart failure.

Diabetes Mellitus and Cardiomyopathy as Presenting Features of Occult Malignant Pheochromocytoma.

The concomitant occurrence of diabetes mellitus and cardiomyopathy secondary to occult malignant pheochromocytoma has rarely been reported. This case report describes the case of a 48-year-old female with a previous history of diabetes mellitus, hypertension, and cardiomyopathy who presented with fatigue and significant weight loss. Neither typical symptoms of pheochromocytoma nor metastatic symptoms were presented. Pheochromocytoma with extension to the liver was incidentally found from computed tomography of the abdomen and laboratory investigations during the work-up to identify the cause for the weight loss. Right adrenalectomy and a right hepatectomy were performed. Malignant pheochromocytoma was diagnosed based on pathology. All of her underlying conditions including diabetes mellitus, hypertension, and cardiomyopathy, were improved following the complete resection of the tumor. This case emphasizes the importance of early suspicion and diagnosis of malignant pheochromocytoma in individuals with atypical presentation of a chromaffin-secreting tumor.

Cheating Death: A Rare Case Presentation of Kratom Toxicity.

Kratom is a psychoactive herb that has been gaining widespread popularity due to its ease of availability and opiate-like effects. While it has been used beneficially as a method of weaning off opiate addictions, it does have a host of toxic effects when misused or abused. There has been a wide spectrum of negative effects including renal failure, liver failure, and cardiac toxicity. While some adverse effects have been reversed with medical intervention, others left more of a detrimental long-term impact not amenable to even the most invasive therapies. We present the case of a patient who was admitted to the intensive care unit after presenting with unresponsiveness secondary to a cerebrovascular accident, rhabdomyolysis, and renal failure. The patient had begun using kratom, initially for recreational purposes, and later escalating it to abusive doses. The patient survived the episode after suffering many complications including transient reversible nonischemic cardiomyopathy and was discharged in a neurologically stable state; however, he ended up being hemodialysis-dependent at such an early age. Rhabdomyolysis is a rare complication of this herb that has not been well documented.

Methamphetamine Associated Cardiomyopathy in Pregnancy: The Distinctions and the Implications.

Introduction: Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process. Clinical Findings and Outcomes: This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean section. The patient's course was also complicated by chronic methamphetamine use with a possible withdrawal component, which resulted in rapid sequence intubation and mechanical ventilation. Ultimately the patient's respiratory and cardiac symptoms resolved with appropriate treatment. Resolution of reduced ejection fraction was also demonstrated by repeat echocardiogram. Conclusions: In this article, we will compare the pathophysiology, diagnostic criteria, treatment and prognosis of MAC, specifically in pregnancy, versus PPCM. We also discuss how we ultimately conclude that a diagnosis of MAC can be made rather than PPCM or stress cardiomyopathy. We also find that studies involving methamphetamine use in pregnancy are limited, and ultimately more longitudinal data is needed to achieve a better understanding of patient outcomes, especially given the increasing prevalence of methamphetamine use in the United States.

A Mid-Ventricular Variant of Takotsubo Cardiomyopathy: A Case Study and Review of Literature.

Different variants of Takotsubo cardiomyopathy (TC) have been described recently. In the present case, we report a post-menopausal woman who had been experiencing significant emotional distress, admitted with typical chest pain, electrocardiographic changes, and elevated troponin levels. She underwent left heart catheterization that demonstrated mild non-obstructive coronary disease and mid-ventricular focal wall motion abnormality, consistent with the mid-ventricular variant of TC. One month after her discharge, a repeated echocardiogram showed preserved ejection fraction and no wall motion abnormalities. In the mid-ventricular variant, we usually observe a unique end-systolic appearance that resembles a Greek vase. It is possible that atypical patterns of left ventricle (LV) dysfunction related to TC are being underrecognized. Therefore, this case study highlights the importance of recognizing less frequent variants of TC.

Takotsubo Cardiomyopathy: Is It Due to Adrenal Crisis or Sjogren's Flare?

Takotsubo cardiomyopathy is a form of reversible cardiomyopathy. It is usually due to sudden emotional or physical stress. It is associated with excessive sympathetic stimulation and catecholamine release. Patients have a very similar presentation to an acute coronary syndrome with patent coronaries. We present a case of takotsubo cardiomyopathy in a patient who has a history of Sjogren's disease on a steroid taper.

Acute reversible cardiomyopathy and heart failure in a child with acute adrenal crisis.

Acute adrenal crisis is a life-threatening disorder. Cardiovascular complications of the condition are usually limited to hypovolaemic hypotension and shock. An acute reversible cardiomyopathy and heart failure in association with acute adrenal crisis is rarely reported, particularly in children. A 6-year-old girl with adrenal crisis which was complicated by acute reversible cardiomyopathy is reported. Inotropic and ventilatory support in addition to intravenous hydrocortisone and furosemide therapy were required to achieve cardiovascular stability. The cardiomyopathy resolved over 5 days and she was discharged with normal cardiac and intellectual functions. Cardiomyopathy should be considered in patients with acute adrenal crisis demonstrating any symptoms or signs of heart failure.

Two Cases of Stress Cardiomyopathy during Esophagogastroduodenoscopy.

Esophagogastroduodenoscopy (EGD) is considered a relatively safe procedure. However, the procedure and the materials used in EGD with conscious sedation can cause stress to the patient. Adverse events during EGD have been reported, represented by cardiopulmonary complications. To date, five cases have reported worldwide to be associated with gastrointestinal endoscopy. Stress cardiomyopathy (SCMP) is a reversible cardiomyopathy that typically occurs in postmenopausal women due to stress and may resolve within a few weeks. SCMP resembles acute myocardial infarction but differs in terms of treatment and prognosis. Here, we describe two cases of SCMP with shock during EGD with conscious sedation.