Caught in the Trap: Takotsubo Cardiomyopathy Masquerading as Acute Hypoxic Respiratory Failure" a case report

Bilal Muhammad¹, Cindy Nguyen¹, Khurram Arshad^2*, Rabia Latif³, Farman Ali², Yazan Alamro², Siri Vallabah Reddy¹, and Mohsin Ahmad¹

¹Department of Internal Medicine Merit Health Wesley, Hattiesburg, Mississippi, USA

²Department of Internal Medicine Corewell Health Dearborn Hospital, Dearborn, MI USA

³Department of Internal Medicine McLaren Flint Hospital, Flint, MI USA

^*Corresponding author: : Khurram Arshad, MD, Department of Internal Medicine Corewell Health Dearborn Hospital, Dearborn, MI USA

 Received: 05 April 2024; Accepted: 12 April 2024; Published: 00 April 2024

1. Introduction

Japanese fishermen refer to it as an octopus trap, whereas physicians call it Gebrochenes-Herz syndrome. Takotsubo syndrome (TTS) is a reversible non-ischemic cardiac pathology characterized by regional wall motion abnormalities easily detectable on an echocardiogram. These abnormalities affect areas supplied by more than one vessel. Despite an unknown etiology, multiple associated factors have been identified. These include sudden catecholamine surges, both endogenous (secondary to anaphylaxis and severe emotional stress) and exogenous (administration of catecholamines routinely used to treat anaphylactic reactions) [1] as well as stimulant drug use like amphetamines, cocaine [3], and acute ischemic stroke [2]. We report a case of Takotsubo cardiomyopathy presenting as acute hypoxic respiratory failure requiring invasive ventilation.

Case presentation: A 73-year-old female with a past medical history significant for hypertension, brain aneurysm status post coiling x 2, ventriculoperitoneal shunt placement, hyperlipidemia, GERD, vocal cord polyps, and generalized anxiety disorder presented to our hospital with concerns of angioedema and anaphylactic reaction.

Events before arrival at the hospital: The patient was found by her son in her room, experiencing shortness of breath and inability to speak, prompting a call to emergency medical services. The patient received 0.6 mg of epinephrine during transport and nebulized ipratropium and albuterol twice without significant improvement. The patient's last known normal baseline was reported at 11:30 AM, with her son discovering her around 4 PM, drooling. Family members suggested possible recent exposure to fiberglass during construction work, raising concerns of an allergic reaction.

Hospital course: Upon arrival at the emergency room, the patient was still drooling, reported throat swelling, and appeared disoriented but responsive. She could easily follow commands and requested a pen and paper to write her medical history. With worsening symptoms and hypoxia, her saturation dropped to the low 80s, prompting elective intubation because of concerns of worsening angioedema and suspected stroke.

She was admitted to the ICU for further evaluation and management as there were concerns for angioedema and suspected cerebrovascular events. A stroke workup, including a CT scan of the head without contrast, showed a right ventricular shunt in place without evidence of hydrocephalus or any acute changes. Lab work on presentation showed an unremarkable complete blood count, slightly elevated thromboplastin time of 42.5, clear urinalysis, metabolic profile concerning elevated glucose of 199, elevated cholesterol 263, lipoprotein HDL 161, LDL 72, troponin 517. Serial EKGs were done, and troponins were trended, with the highest value recorded at 3222 (normal upper limit of 66). Loading doses of aspirin and high-dose statin were initiated.

Further workup, including carotid ultrasound, showed no significant stenosis, and a CT angiogram of the head and neck did not show any occlusive changes, vascular stenosis, or hemorrhages. Upon contacting the family on day 2, it was later revealed that the patient had a cat that she had been taking care of for the last ten years, and it had passed approximately a week ago. She was in severe emotional distress, secondary to that.

As a part of the stroke workup, a transthoracic echocardiogram was ordered to rule out any ASD or PFO. However, to our surprise, it revealed the classic findings of apical ballooning with a hyperdynamic base suggestive of Takotsubo cardiomyopathy versus triple-vessel disease and an ejection fraction of 35 to 40% with grade 1 diastolic failure.

Figure1: The left ventricle can be visualized with a normal diastolic filling pattern

Figure 2: shows classic apical ballooning during systole

Figure 3: resembling an inverted octopus trap

The left ventricle can be visualized with a normal diastolic filling pattern in Figure 1, whereas Figure 2 shows classic apical ballooning during systole, resembling an inverted octopus trap, as seen in Figure 3.

Cardiology was consulted and recommended to continue aspirin and statin, and performed a left heart catheterization to rule out ischemic cardiomyopathy, which showed no obstructive coronary artery disease and decreased ejection fraction and classical findings of TTS as shown in the following images.

Figure 4: demonstrates normal coronary arteries without any significant obstruction

Figure 5: shows classical apical ballooning during systole

Figure 6: shows classical apical ballooning during systole

Figure-4 demonstrates normal coronary arteries without any significant obstruction. Figure 5-6 shows classical apical ballooning during systole.

The diagnosis of Takotsubo cardiomyopathy was established. The following morning, she was extubated with no post-extubation complications, and the cardiology team started her on guideline-directed medical therapy, including ACE, ARB, and spironolactone, and she was discharged to a rehab facility on the eighth post-admission day.

Discussion

Takotsubo syndrome, first described by [4] in 1990, has an estimated incidence of 1-3% [5], with a predilection for elderly females [6, 7, 8]. Although age itself doesn't significantly impact outcomes, extremes in age present predictable risks, such as arrhythmias in younger patients and heart failure in older adults [9]. The pathophysiology remains unclear, with proposed mechanisms including coronary vasospasm, microcirculatory dysfunction, and catecholamine excess [10]. One of the most commonly presenting and worked-up symptoms in the hospital is chest pain, which is usually linked to cardiac events. Physicians are prone to overlook hypoxic respiratory failure with dyspnea as a cardiac symptom, instead attributing it to some underlying pulmonary pathology secondary to confirmation bias. Interestingly, one of the common presenting symptoms of TTS is new-onset dyspnea. While reliable scoring systems such as InterTak [11] score exist, they are rarely used in the hospital setting to evaluate someone presenting with new onset dyspnea. Our patient presented with new onset dyspnea with hypoxic respiratory failure requiring intubation, which raised concerns for anaphylaxis or stroke secondary to the history provided by family members. Both were later ruled out as CT scan head, CTA head, and neck were unremarkable, and there was no visible laryngeal edema during intubation. Being intubated during the presentation, it was challenging for us to obtain a detailed medical history from the patient and establish a timeline of events, which we could do later as we had more details from different family members and the patient herself. She had some mild troponin elevation to 513, which later up-trended to 3222. However, her serial EKGs were unremarkable, and she denied any chest pain. Takotsubo has been linked with the exogenous administration of epinephrine for allergic reactions in the past [12]. This could be the case for our patients. However, the recent stressor of her cat dying could have also led to her symptoms. We are reporting this case as we believe that TTS can present with hypoxic respiratory failure with new onset dyspnea, which anyone can easily confuse with an anaphylactic reaction or a stroke. Luca et al. [13] evaluated the GIEST (German Italian Takotsubo) registry and hypothesized that the dyspnea on the presentation could be used as a prognostic factor for patients. While most cases present with chest pain with associated dyspnea, there have been multiple case reports in the past where TTS diagnosis was elusive and the only presenting symptom was dyspnea [14-36], and there has been a similar case to our patient where an elderly female presented with dyspnea [19]. Mention the timeline table for our patient. In these cases, the main presenting symptom was new onset dyspnea instead of chest pain.

Management

Depending on its presentation, TTS is usually managed conservatively, with the most important factor being the removal of the stressor. If a patient presents with cardiogenic shock, a trial of dopamine and dobutamine can be used, keeping left ventricular out-flow in mind.

Conclusion

TTS is a well-known condition, and multiple cases have been reported since its initial description in 1990. The primary presenting symptom in the majority of cases is chest pain. However, a subset of patients presents solely with worsening hypoxic respiratory failure, which can be mistaken for anaphylaxis, airway compromise, or a new onset cerebrovascular accident (CVA). There should be a high index of suspicion for Takotsubo cardiomyopathy in these patients, particularly if they match a specific patient profile, such as elderly post-menopausal females with recent stressful events. TTS is reversible and is typically managed similarly to heart failure. We recommend that all elderly females with otherwise unexplained new-onset dyspnea in the context of recent stressful life events undergo screening with point-of-care ultrasound for TTS upon presentation.

Conflicts of interest for all authors:

None to declare

References

1. Khoueiry G, Abi Rafeh N, Azab B, et al. Reverse Takotsubo cardiomyopathy in the setting of anaphylaxis treated with high-dose intravenous epinephrine. J Emerg Med 44 (2013): 96-99.
2. Morris NA, Chen ML, Adejumo OL, et al. Stroke Risk Following Takotsubo Cardiomyopathy. The Neurohospitalist 10 (2020): 277-280.
3. Sundbøll J, Pareek M, Høgsbro M, et al. Iatrogenic takotsubo cardiomyopathy induced by locally applied epinephrine and cocaine. BMJ Case Rep 19 (2014): 2013202401.
4. Satoh H, Tateishi H, Ushida T, et al. Takotsubo-type cardiomyopathy due to multivessel spasm Clinical aspects of myocardial injury: from ischemia to heart failure (in Japanese) 1990. Tokyo: Kagakuhyoironsya Co 4 (2012): 56-64.
5. Matta A, Delmas C, Campelo-parada F, et al. Takotsubo cardiomyopathy. Rev Cardiovasc Med 23 (2022):38.
6. Ghadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J 39 (2018): 2032-2046.
7. Cammann VL, Szawan KA, Stahli BE, et al. Age-related variations in takotsubo syndrome. J Am Coll Cardiol 75 (2020):1869-1877.
8. Pelliccia F, Kaski JC, Crea F, et al. Pathophysiology of takotsubo syndrome. Circulation 135 (2017): 2426-2441.
9. Huseynov A, El-Battrawy I, Ansari U, et al. Age-related differences and outcome of patients with Takotsubo syndrome. J Geriatr Cardiol 14 (2017): 632-638.
10. Hasan SM, Patel JD, Faluk M, et al. Takotsubo cardiomyopathy and its variants: A case series and literature review. J Community Hosp Intern Med PersPerspect 10 (2020): 210-215.
11. Samul-Jastrzebska J, Roik M, Wretowski D, et al Evaluation of the InterTAK Diagnostic Score in differentiating Takotsubo syndrome from acute coronary syndrome. A single center experience. Cardiol J 28 (2021): 416-422.
12. Nazir S, Lohani S, Tachamo N, et al. Takotsubo cardiomyopathy associated with epinephrine use: A systematic review and meta-analysis. Int J Cardiol 229 (2017): 67-70.
13. Arcari L, Musumeci MB, Stiermaier T, et al. Incidence, determinants and prognostic relevance of dyspnea at admission in patients with Takotsubo syndrome: results from the international multicenter GEIST registry. Sci Rep 10 (2020): 13603.
14. Lee SE, Yoon SH, Kang HJ, et al. Takotsubo syndrome as an overlooked and elusive cause of a single episode of dyspnea in young women: a case report. BMC Cardiovasc Disord 21 (2021): 430.
15. Chauhan R, Brown B, Ahmed A, et al. A Case Report on Takotsubo Cardiomyopathy. Cureus 15 (2023): e45285.
16. Hiruma T, Higuchi R, Iguchi N. Quadruple episodes of takotsubo cardiomyopathy: a case report. Eur Heart J Case Rep 5 (2021): 574.
17. Ruiz S, Martinez-Marin M, Luque P, et al. Takotsubo cardiomyopathy after cesarean section: A case report and literature review. J Obstet Gynaecol Res 43 (2017): 392-396.
18. Ortuno S, Jozwiak M, Mira JP, et al. Case Report: Takotsubo Syndrome Associated With Novel Coronavirus Disease 2019. Front Cardiovasc Med 8 (2021): 614562.
19. Iuliano G, Napoletano R, Vecchione C, et al. A case report of takotsubo syndrome complicated by ischaemic stroke: the clinical dilemma of anticoagulation. Eur Heart J Case Rep 5 (2021): 051.
20. Agarwal M, Kardos A. A case report: biventricular takotsubo cardiomyopathy with sequential ventricular recovery due to pulmonary hypertension. Eur Heart J Case Rep 5 (2021): 073.
21. Chauhan R, Brown B, Ahmed A, et al. A Case Report on Takotsubo Cardiomyopathy. Cureus 15 (2023): e45285.
22. Malley T, Watson E. A case of Takotsubo cardiomyopathy after chemotherapy. Oxf Med Case Reports 2016 (2016): 55-58.
23. Tsugu T, Nagatomo Y, Nakajima Y, et al. Biventricular takotsubo cardiomyopathy with asymmetrical wall motion abnormality between left and right ventricle: a report of new case and literature review. J Echocardiogr 17 (2019): 123-128.
24. Ichihara N, Fujita S, Kanzaki Y, et al. Basal wall hypercontraction of Takotsubo cardiomyopathy in a patient who had been diagnosed with dilated cardiomyopathy: a case report. BMC Cardiovasc Disord 17 (2017): 293.
25. Bonfanti L, Buratti S, Vignali L, et al. Takotsubo cardiomyopathy in an ultra-centenarian woman. Acta Biomed 88 (2018): 529-532.
26. Tomida M, Fujimoto N, Moriwaki K, et al. Peripartum Mid-Ventricular-Type Takotsubo Cardiomyopathy After Cesarean Delivery. Int Heart J 63 (2022): 782-785.
27. Inoue H, Nishimura T, Nojima T, et al. Takotsubo Cardiomyopathy Caused by Carbon Dioxide Intoxication. Cureus 13 (2021): e14179.
28. Elikowski W, Malek-Elikowska M, Fertala N, et al. Takotsubo syndrome triggered by emotional and physical stress due to coincidental immobilization resembling the experimental model of the disease - a case report. Pol Merkur Lekarski 45 (2018): 154-157.
29. Iwase J, Yamanaka M. Sudden onset of pheochromocytoma multisystem crisis at 38 weeks of gestation resulted in intrauterine fetal death: A case report. J Obstet Gynaecol Res 43 (2017): 1644-1648.
30. Kurisu S, Ishibashi K, Kato Y, et al. Tako-tsubo cardiomyopathy complicated by QRS prolongation. Intern Med 51 (2012): 291-294.
31. Bilan A, Ignatowicz A, Mosiewicz J, et al. Dyspnea as a dominant clinical manifestation in a patient with takotsubo cardiomyopathy treated for chronic obstructive pulmonary disease and hyperthyroidism. Pol Arch Med Wewn 119 (2009): 265-268.
32. Garla VV, Gosi S, Kanduri S, et al. A case of catecholamine-induced cardiomyopathy treated with extracorporeal membrane oxygenation. BMJ Case Rep 12 (2019): e230196.
33. Tsuji M, Isogai T, Okabe Y, et al. Ventricular Septal Perforation: A Rare but Life-Threatening Complication Associated with Takotsubo Syndrome. Intern Med 57 (2018): 1605-1609.
34. Garla VV, Gosi S, Kanduri S, et al. A case of catecholamine-induced cardiomyopathy treated with extracorporeal membrane oxygenation. BMJ Case Rep 12 (2019): e230196.
35. Nguyen LT, Schelbert EB, Cook SC. Takotsubo Cardiomyopathy in an Adult Woman With Repaired Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 7 (2016): 381-384.
36. Sato R, Ohshima N, Masuda K, et al. A patient with relapsing polychondritis who had been diagnosed as intractable bronchial asthma. Intern Med 51 (2012): 1773-1778.