Takotsubo cardiomyopathy in the setting of a myasthenic crisis

Myasthenic crisis-induced Takotsubo cardiomyopathy: a case report

Introduction and importance

Myasthenic crisis (MC) is characterized by severe weakness in the bulbar and respiratory muscles. Takotsubo cardiomyopathy (TC) is a rare clinical entity mainly associated with postmenopausal women. We report a case of both these conditions in a premenopausal woman.

Case presentation

A 31-year-old woman with hypothyroidism presented with dyspnea. Bedside echocardiography in the ICU revealed an apical ballooning with an ejection fraction of 25%, and she was treated with losartan, furosemide, and spironolactone. She was intubated after 2 days as she developed respiratory distress and type II respiratory failure. Upon investigation, the patient tested positive for anti-acetylcholine receptor antibody. Treatment with five doses of IVIG (intravenous immunoglobulin) was given, and she made a remarkable recovery. Repeat echocardiography revealed her ejection fraction is normal and cardiac function is resolved.

Clinical discussion

The association between TC and MC is unusual and not commonly observed. MC can be a natural progression of myasthenia gravis or due to stressors, such as infection, medicine, pregnancy, and surgery. Stressful events can lead to TC. This leads to the possibility of TC, along with other cardiac complications, in patients with MC.

Conclusion

Patients with MC may be at potential risk of developing TC, thus careful cardiac monitoring is necessary while treating them for a better prognosis.

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases

Introduction

Takotsubo cardiomyopathy (TCM) features transient left ventricular apical dysfunction or ballooning. The underlying mechanism remains elusive; however, evidence suggests the role of different physical and psychological stressors. We systematically reviewed patients presenting with TCM and autoimmunity to explore the link between the two conditions.

Methods

We applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report this review. Using keywords related to autoimmune/immune-mediated diseases and TCM, we searched PubMed, Scopus, and WOS in March 2022. The final results were added to a data extraction sheet. Data were analyzed by SPSS version 26.0.

Results

Our search yielded 121 studies, including 155 patients. Females were considerably predominant. Most patients had a history of autoimmune disease, and almost a third had a history of cardiovascular disease. Dyspnea and chest pain were the most common chief complaints. More than 70% of patients had experienced physical stress. Myasthenia gravis, systemic lupus erythematosus, and multiple sclerosis were the most frequently reported autoimmune diseases.

Conclusion

There were similarities in age and sex compared to classic TCM. TCM should be considered as a differential diagnosis for ACS, especially in patients with a positive background of autoimmunity. A precise reporting system is required for further studies.

A Case Report and 31-Case Study: Does Takotsubo Cardiomyopathy in Myasthenia Gravis Patients Have a High Mortality Rate?

Myasthenia gravis is an autoimmune disorder in which antibodies are formed against post-synaptic nicotinic acetylcholine receptors that lead to impeded muscle contraction and commonly affects the oculomotor muscles. Takotsubo cardiomyopathy (TTC) is a dilated cardiomyopathy that can mimic a myocardial infarction and causes reversible systolic dysfunction. This is a case of a 66-year-old Caucasian male with a known history of ocular myasthenia gravis that presented to the emergency room with worsening dyspnea secondary to a myasthenic crisis. One day, following admission, his shortness of breath failed to improve and was found to meet the diagnostic criteria for takotsubo cardiomyopathy. A brief review of 31 previous cases summarizes the current case reports, patterns, and mortality associated with the myasthenic crisis associated with TTC.

A myasthenic crisis of broken hearts (reverse takotsubo): Case report and review of literature

Myasthenic crisis (MC) is rarely associated with takotsubo cardiomyopathy (TTC), but embolic complications of MC-associated reverse TTC are yet to be documented. We present a case of a 70-year-old Caucasian female with MC-associated reverse TTC, developing acute cerebral infarcts. Following aggressive treatment with immunoglobulins and anticholinergics, cardiac function normalised. TTC is an important differential diagnosis in acute deteriorations of cardiac function, particularly in intensive care, not only due to frequent use of inotropes and embolic complications but also because cardiac function is reversible with good medical care. Early specialist neurologist and cardiologist input should be sought in such cases.