Takotsubo cardiomyopathy following envenomation: An updated review

Scorpion-Induced Acute Coronary Syndrome: A Stinging Complication

The Tityus trinitatis, a black scorpion species endemic to the fauna of Trinidad, has been implicated in envenomation with devastating clinical sequelae such as acute pancreatitis and major adverse cardiovascular events. We present the first in-Caribbean case of a 59-year-old Caribbean South Asian male with human immunodeficiency virus who presented with a non-ST-segment-elevation acute coronary syndrome after being stung, which was managed with comprehensive, guideline-directed medical therapy. The clinician should be cognizant of scorpion-induced acute coronary syndrome (ACS) as a potential sequela of envenomation and its clinical management.

Takotsubo cardiomyopathy following scorpion envenomation: a literature review

BACKGROUND

Takotsubo syndrome is comparable to microvascular acute coronary syndrome. It may partly share the same pathophysiology debated during scorpion envenomation (SE), with an adrenergic storm, without myocardial infarction due to the absence of coronary artery stenosis. Takotsubo cardiomyopathy can help to better understand the pathophysiology of cardiac involvement during scorpion envenomation. However, Takotsubo syndrome seems to be underestimated in the literature in patients suffering from cardiac failure following SE.

METHODS

In this review, we aimed to detail all described cases, the mechanism, and outcomes of scorpion envenomation complicated by Takotsubo cardiomyopathy. We used the PubMed database by using the following keywords in MeSH research: scorpion envenomation, Takotsubo cardiomyopathy, and Takotsubo syndrome.

RESULTS

The literature analysis showed the existence of only four cases of confirmed Takotsubo cardiomyopathy following severe SE. All four patients developed a transient reversible left ventricular systolic dysfunction in the absence of coronary artery disease, following a positive history of scorpion envenomation. A cardiac MRI was performed in all cases, showing a ballooning in the left ventricle associated with a left ventricular ejection fraction in all cases. All patients were improved under symptomatic treatment, and complete recovery of the wall motion was observed.

CONCLUSION

Takotsubo syndrome, although not often reported in the literature in severe SE, can represent an effective hypothesis explaining the pathophysiology of cardiac involvement during SE. In severe scorpion envenomation, multiple mechanisms exist and can explain the development of Takotsubo syndrome. Its management is based on oxygen, with invasive or non-invasive ventilator support in patients with respiratory failure and/or cardiogenic shock. Beta-blockers, mineralocorticoid receptor antagonists, and diuretics are usually used in Takotsubo syndrome. However, in severe scorpion envenomation, all reported cases of Takotsubo cardiomyopathy are associated with cardiogenic shock and acute pulmonary edema. As a consequence, we advise the use of Dobutamine since it has already been confirmed that cardiac dysfunction following scorpion envenomation improves well and safely under Dobutamine infusion.

Sudden death after a bite by a lowland swamp viper (Proatheris superciliaris) in Malawi: Dying of fright?

Proatheris superciliaris, the lowland swamp viper, has a limited distribution along lakeshores and rivers in Malawi, Southern Tanzania, and central Mozambique. Its venom is known to be procoagulant. Only five P. superciliaris bites have been reported, all inflicted by captive snakes, and none was fatal. Here we present a case of sudden death following a bite by Proatheris superciliaris in rural Malawi that cannot be attributed to envenoming. A healthy 32-year-old woman was planting rice in a flooded rice paddy field when she suddenly told her sister in a quiet voice that she had been bitten by a snake. She then collapsed face-upwards into the ankle-deep water. She remained motionless while her sister and uncle carried her out of the rice paddy onto dry land a few meters away. The victim did not regain consciousness. Her uncle heard one exhalation but no further breathing. The snake responsible was killed by a friend. Although the venom of this species can cause life-threatening coagulopathy, this woman's death occurred too rapidly to be attributable to envenoming. Only two explanations seem plausible: anaphylaxis, or vasovagal shock triggered by fear. In the present case, the victim died within minutes of the bite, closely observed by her anxious relatives, but showed no features of anaphylaxis. In Malawi, as in much of sub-Saharan Africa, many people are reportedly terrified of snakes, believing that bites by almost any species can cause rapid death. In this case, death occurred less than 2 min after a bite from Proatheris superciliaris. We believe that the cause of death was most likely a severe vasovagal attack, in response to the fear and pain of the snakebite that triggered vasodilatation, bradycardia, and hypotension leading to cardiac arrest.

Cardiovascular complications following medical termination of pregnancy: An updated review

BACKGROUND

Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described.

AIM

To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP.

METHODS

We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications".

RESULTS

The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications.

CONCLUSION

In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.