Catecholamine-Induced Secondary Takotsubo Syndrome in Children With Severe Enterovirus 71 Infection and Acute Heart Failure: A 20-year Experience of a Single Institute

Figures

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  Figure 1. Sagittal magnetic resonance imaging of the brain reveals high signal intensity over the dorsal regions of the brain stem and cervical spinal cord in a 16-month-old patient with severe enterovirus 71 infection and acute heart failure in the year 2001 (A). Chest radiography demonstrates bilateral pulmonary edema and a normal heart size. The ejection fraction of the left ventricle was 27% as measured by echocardiography at this time (B).

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  Figure 2. Transthoracic two-dimensional echocardiogram in the apical four-chamber view shows a mid-ventricular pattern of a circumferential regional wall motion abnormality with conspicuous apical ballooning of the LV in a 20-month-old patient in the year 2000 (A) (also see Supplementary Video 1). Diagram demonstrates the apical ballooning shape of the LV with an appearance resembling an octopus pot (called Tako-tsubo) (B). Transthoracic color Doppler echocardiogram in the parasternal long-axis view shows LV dysfunction with a circumferential regional wall motion abnormality resulting in apical ballooning of the LV during systole, and mild mitral regurgitation in a 3-year-old patient in the year 2018 (C) (also see Supplementary Video 2). An M-mode echocardiographic recording from the level of the mitral valve chordae to the level of the mitral valve reveals a circumferential LV regional wall motion abnormality along yellow and red lines (D). Ao, aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

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  Figure 3. Box-plots show significant elevation of plasma and urine catecholamine concentrations in patients with enterovirus 71-related heart failure. Dash lines indicate individual upper limits of normal. ♦, Outliers: the patient's values that are between 1.5 and 3 box lengths from either end of the box. Epi, epinephrine; NE, norepinephrine.

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  Figure 4. The postulated pathogenesis of severe EV71 infection associated with catecholamine-induced secondary Takotsubo syndrome (TTS). Central nervous system indicates central nervous system; EV71, enterovirus 71; HFMD, hand-foot-and-mouth disease; LV, left ventricular; and S1–4, Stage 1–4.