Takotsubo cardiomyopathy associated with status epilepticus

Sirs, A 62-year-old Chinese male with no previous history of seizures was admitted with status epilepticus necessitating intravenous lorazepam, propofol and endotracheal intubation. He became hypotensive and an ECG showed ST-segment elevation in the anterior precordial leads. Cardiac enzymes were elevated. He did not have any cardiovascular risk factors. Bedside echocardiogram showed mildly impaired left ventricular ejection fraction of 40% with mid-ventricular ballooning and relative sparing of the apex (Fig. 1). Coronary angiogram revealed a non-significant stenosis in the obtuse marginal branch of the left circumflex artery. A diagnosis of Takotsubo (stress-induced) cardiomyopathy was made. The patient subsequently made an uneventful cardiac recovery. Repeat echocardiogram 6 weeks later was normal. MRI of the brain showed encephalomalacia of the right basal frontal lobe with old lacunas in bilateral external capsules, bilateral corona radiata and right hemipons. Echocardiogram demonstrating mid-cavity ballooning during systole. First described in Japan, Takotsubo cardiomyopathy is characterized by transient left ventricular apical or mid-cavity ballooning and ECG changes that mimic an acute coronary event, but in the absence of significant coronary artery disease. It may be associated with hypotension or tachyarrhythmias, and is thought to be due to catecholamine-induced coronary microcirculatory spasm [1–3]. The precipitating event is usually intense physical or mental stress or an acute medical illness. This case is unusual in a few respects. First, it is rare for Takotsubo cardiomyopathy to occur in the setting of status epilepticus. There has only been one other case report in the literature [4]. Secondly, this entity which has a predilection for middle-aged women (82–100% of cases) has occurred in a male patient in this case [1,3]. Thirdly, the left ventricular ballooning in Takotsubo cardiomyopathy usually occurs at the apex instead of the mid-cavity [5–7]. Whilst still a diagnosis of exclusion, Takotsubo cardiomyopathy remains an important differential to consider in the setting of ECG changes occurring with an acute medical illness, not least, because the associated systolic dysfunction is reversible and the prognosis is good if patients survive the acute event [3,8]. None.