Critically ill patients with Takotsubo cardiomyopathy

Background

A cardiac syndrome of 'apical ballooning', also named Takotsubo cardiomyopathy, consists of an acute onset of transient akinesia of apical and mid portions of the left ventricle, without significant coronary stenosis. It is considered to be trigged by emotional stress. Recently, it has also been described in critically ill patients. Cardiogenic shock can occur but is not usual.

Objective

To describe one HIV patient with Takotsubo cardiomyopathy in an ICU admission.

Methods and results

NSB, a Caucasian 54-year-old female, with previous history of anemia and depression, was admitted to the ICU due to altered mental status. Her family reported mood changes and lethargy. Her physical examination showed oral candidiasis and loss of consciousness. After ventilatory support, an MRI image was obtained showing ring-enhancing mass lesions suggesting intracerebral toxoplasmosis. Folinic acid, pyrimethamine and sulfadizine were initiated. Screening and confirmatory tests were positive for HIV.

Over the following days the patient developed haemodynamic instability requiring intravenous vasopressors. Troponin, CKMB and CK were normal and the ECG showed an inverted T wave in leads V2–V5. An echocardiography showed anteroapical akinesia. The cardiac catheterization did not reveal any obstructive coronary lesion; however, ventriculography demonstrated an abnormal left ventricle with anterioapical akinesia. After 3 days, the patient was stable and without inotropic support. In a second echocardiography, the left ventricular wall motion was normal.

Conclusion

Critically ill patients can present a cardiomyopathy with reversible anteroapical akinesia without coronary stenosis. This diagnosis should be considered among ICU patients.