SESSION TITLE: Critical Care Student/Resident Case Report Posters IV
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Guillain-Barre Syndrome (GBS) is a disease that typically presents following an acute infectious process. It is a polyneuropathy affecting the peripheral nervous system resulting in an ascending paralysis with weakness beginning in the feet and hands and migrating towards the trunk. It is now well documented that myocardial dysfunction in GBS can be linked to Takotsubo Cardiomyopathy by means of a transient hyperadrenergic state and should be considered in the work-up of the hemodynamically unstable patient with clinical signs of congestive heart failure.
CASE PRESENTATION: 44-year-old African-American female with known history of Ulcerative Coltis and Schizophrenia presented with progressive areflexia and tetraparesis that developed after a week long diarrheal illness. She was subsequently diagnosed with GBS. She developed chest pain and EKG changes showing T wave inversions. Troponin I was 2.1 ng/ml (reference range<0.03ng/ml ) and CK-MB was 27.9ng/ml (reference range < 5.9ng/ml). A preliminary diagnosis of acute coronary syndrome was suspected. Chest x-ray revealed pulmonary vasculature engorgement. Patient was intubated due to respiratory failure. She developed profound hypotension due to dysautonomia of GBS. A 2-D echocardiogram ( Fig. 1) showed extensive global dyskinesia of left ventricle with hypokinesia and ballooning of apex and hyperkinesia of base. Estimated ejection fraction was 12%. Cardiology was consulted diagnosing her with Takotsubo cardiomyopathy. She was started on Aspirin, statin and subsequently a beta blocker. At two and four week follow-up, repeat echocardiogram showed near-complete resolution of the apical wall motion abnormalities and an ejection fraction of 50-55% (Fig. 2).
DISCUSSION: Takotsubo cardiomyopathy is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle that mimics myocardial infarction in the absence of obstructive coronary artery. Stress-induced cardiomyopathy was first described in Japan and the term “Takotsubo” is taken from the Japanese name for an octopus trap, which has a shape that is similar to the apical ballooning configuration of left ventricle in the systole. It is not known why the left ventricle mid cavity or apex are predominantly affected. Postulated mechanisms include catecholamine excess, coronary artery vasospasm, and microvascular dysfunction.
CONCLUSIONS: Observation supports that GBS can be linked to Takotsubo syndrome by means of profound dysautonomia or by means of stressful trigger of GBS occurrence. Therefore, transthoracic echocardiography should be systematically performed when repolarization abnormalities are present in the disease to rule out a Takotsubo syndrome, even in asymptomatic patient.
Reference #1: J Neurol Sci. 2010 Apr 15;291(1-2):100-2. doi: 10.1016/j.jns.2010.01.005. Epub 2010 Feb 1.
Reference #2: Int J Cardiol. 2012 Nov 22. pii: S0167-5273(12)01458-1. doi: 10.1016/j.ijcard.2012.10.083.
DISCLOSURE: The following authors have nothing to disclose: Roderick Fontenette, Cheryl Moses, Omar Rahman, Amir Habib, Jennifer Croix, Micjae; Sutton
No Product/Research Disclosure Information