Okonkwo Enola R, Schuetz Christian, Hyman Bryan, Samuels Brian, Sayad Dany, Bower James
Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA.
Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA.
Cureus. 2021 Apr 5;13(4):e14305. doi: 10.7759/cureus.14305.
An underlying cardiomyopathy should be suspected in young patients presenting with ventricular arrhythmias and sudden cardiac arrest. Electrocardiograms revealing epsilon waves are associated with many serious conditions such as arrhythmogenic right ventricular cardiomyopathy, posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report features epsilon waves in a young cardiac arrest patient suspected of having an unrecognized cardiomyopathy that resulted in a fatal arrhythmia in the setting of exogenous bovine thyroid hormone and steroid use. Case presentation: A previously healthy 33-year-old male with a history of anabolic steroid use and bovine thyroid hormone use presented to the emergency department following witnessed cardiac arrest with bystander cardiopulmonary resuscitation (CPR). Upon emergency medical service (EMS) arrival, the patient was in ventricular fibrillation and received defibrillation with the return of spontaneous circulation. In the emergency department, he was unresponsive and required norepinephrine to maintain blood pressure. An epsilon wave and a prolonged QTc interval were noted on his electrocardiogram (ECG). CT angiogram of the chest and CT head were negative for acute abnormalities. Pertinent laboratory work-up included a lactate level of 12.0 mmol/L, thyroid-stimulating hormone of 0.02 ulU/L, and a free thyroxine level of 0.04 ng/dL. Cardiac ultrasound showed globally decreasedleft ventricular function with an ejection fraction of 25-30% and mild dilation of the right ventricle. A cardiac MRI was ordered but the patient had recurrent ventricular fibrillation and was too unstable to complete. He suffered anoxic brain injury with no improvements in neurologic function and was transitioned to comfort care. The patient died two months later in hospice care. The cause of cardiac arrest was attributed to the patient's steroid and bovine thyroid supplementation, but autopsy results revealed histologic evidence of possible arrhythmogenic right ventricular cardiomyopathy. Discussion: Epsilon waves are widely known to be associated with structural abnormalities of the heart, most notably, arrhythmogenic right ventricular cardiomyopathies. Epsilon waves may be present in a variety of other medical conditions including posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report describes an epsilon wave found in a patient with suspected arrhythmogenic right ventricular cardiomyopathy that suffered a fatal arrhythmia triggered by bovine thyroid hormone and steroid use.
对于出现室性心律失常和心脏骤停的年轻患者，应怀疑存在潜在的心肌病。心电图显示有ε波与许多严重疾病相关，如致心律失常性右室心肌病、后壁心肌梗死、右室梗死、浸润性疾病、结节病、Brugada综合征、法洛四联症和体温过低。本病例报告描述了一名年轻的心脏骤停患者出现ε波，怀疑患有未被识别的心肌病，该患者在使用外源性牛甲状腺激素和类固醇的情况下发生了致命性心律失常。病例介绍：一名33岁既往健康的男性，有使用合成代谢类固醇和牛甲状腺激素的病史，在旁观者进行心肺复苏（CPR）后被目击心脏骤停，随后被送往急诊科。紧急医疗服务（EMS）到达时，患者处于心室颤动状态，接受除颤后恢复自主循环。在急诊科，他无反应，需要去甲肾上腺素来维持血压。其心电图（ECG）显示有ε波和QTc间期延长。胸部CT血管造影和头部CT未发现急性异常。相关实验室检查结果包括乳酸水平为12.0 mmol/L、促甲状腺激素为0.02 μIU/L、游离甲状腺素水平为0.04 ng/dL。心脏超声显示左心室功能整体下降，射血分数为25%-30%，右心室轻度扩张。已安排心脏MRI检查，但患者反复出现心室颤动，病情过于不稳定，无法完成检查。他发生了缺氧性脑损伤，神经功能无改善，随后转为舒适护理。患者在两个月后于临终关怀中死亡。心脏骤停的原因归因于患者补充类固醇和牛甲状腺激素，但尸检结果显示有组织学证据提示可能存在致心律失常性右室心肌病。讨论：众所周知，ε波与心脏结构异常有关，最显著的是致心律失常性右室心肌病。ε波也可能出现在多种其他疾病中，包括后壁心肌梗死、右室梗死、浸润性疾病、结节病、Brugada综合征、法洛四联症和体温过低。本病例报告描述了一名疑似致心律失常性右室心肌病患者出现ε波，该患者因使用牛甲状腺激素和类固醇引发了致命性心律失常。
