SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Excessive stimulation of the cortical limbic system is associated with hyperactivity of the catecholamine circuits which can result in cardiac involvement. Hyperactivity of the catecholamine circuits can be precipitated by substance abuse, such as cannabis. Neurogenic cardiomyopathy is an uncommon presentation of cannabis and it can lead to misdiagnosis.
CASE PRESENTATION: A 60-year-old male brought to the ED after persistent retrograde memory loss of 4 days duration. He had a remote tobacco history, did not consume alcohol recently but consumed cannabis 5 days prior. He had no known drug allergy. On examination, he was afebrile, blood pressure was 132/84 mm Hg, and heart rate was 86/minute. Physical examination was unremarkable except for impaired 3 minute recall test. The results of routine biochemical tests were satisfactory. Serial cardiac biomarkers were mildly elevated. UDS was positive for cannabis only. An EKG showed NSR with deep T-wave inversions in anterior leads. TTE revealed severe anterior wall hypokinesia with estimated EF 30-35%. A head CT scan was unremarkable. Head MRI revealed patchy contrast enhancement in the left limbic region without mass effect or evidence of acute infarct, suggestive of limbic encephalitis. An EEG showed no evidence of seizure activity. Heart catheterization showed non obstructive coronary disease and apical ballooning. Further evaluation including viral serology and CSF analysis (chemistry, cell count, viral PCR panel, microbial cultures and cytology) were all unremarkable. A malignancy work up including whole body CT scan, para-neoplastic antibodies and a vasculitis panel were all negative
DISCUSSION: After excluding viral and autoimmune disorders, many patients with limbic encephalitis have CSF, EEG or MRI abnormalities, and rarely, myocardial compromise. Our patient’s cardiac abnormalities included EKG changes, mild elevation of cardiac biomarkers and transient LV dysfunction. A diagnosis of neurogenic stunned myocardium as a manifestation of cannabis induced limbic encephalitis was established. Mini-Mental Status examination towards the end of the hospitalization was noted with deficits in recalls and date abilities. Follow up showed a significant resolution of his EKG, TTE and memory deficit with complete cannabis abstinence
CONCLUSIONS: Over activity of the sympathetic limb is the common phenomenon that associates the major cardiac pathologies seen in neurological insults. It is thus conceivable that overstimulation of catecholamine circuits in the limbic system due to cannabis ingestion could manifest as neurogenic heart disease. Providers should be aware of an uncommon presentation of cannabis ingestion.
Reference #1: Machado, S., A. N. Pinto, and S. R. Irani. 2012. "What should You Know about Limbic Encephalitis? 70 (10): 817-822.
Reference #2: Hagan, I. G. and K. Burney. 2007."Radiology of Recreational Drug Abuse.Radiographics: A Review Publication of Radiological Society of North America,Inc 27(4)919-940.
DISCLOSURE: The following authors have nothing to disclose: Ahmed Abuzaid, Gale Etherton, Amjad Kabach
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