Baker Jiana T, Cury Ricardo, Hernandez-Suarez Dagmar F
Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA.
Radiology, Baptist Health South Florida, Miami, USA.
Cureus. 2024 Dec 16;16(12):e75813. doi: 10.7759/cureus.75813. eCollection 2024 Dec.
Our case report characterizes a rare presentation of mid-ventricular Takotsubo cardiomyopathy (TTC) in a patient with suspected myocarditis as an underlying cause. Mid-ventricular TTC is a rare variant of TTC presenting with overlapping symptoms and physical exam findings of acute coronary syndrome, which often leads to misdiagnosis as myocardial infarction. Our case is of a 77-year-old female patient with a history of hyperlipidemia, right breast ductal carcinoma in situ, and diverticular disease who presented to the emergency department for evaluation of chest pain radiating to the jaw with associated nausea and vomiting. She had a similar event eight months earlier and was diagnosed with ischemia with non-obstructive coronary arteries (INOCA) based on cardiac catheterization findings. Family history was notable for myocardial infarction in the patient's father and paternal grandfather. At presentation, the patient had elevated blood pressure, elevated troponins (initially 1058 ng/L with a repeat level of 11,421 ng/L), and electrocardiogram (ECG) findings of sinus bradycardia without ischemic changes. Cardiac MRI (CMR) revealed sub-epicardial delayed enhancement suggestive of possible myocarditis and diffuse hypokinesis involving the inferolateral left ventricular wall, sparing the basal and apical segments. Left ventricular function was mildly decreased (ejection fraction of 49%) and improved prior to discharge with ejection fraction (55-60%). There were no wall motion abnormalities or significant valve disease. This case presentation exemplifies a rare manifestation of mid-ventricular TTC that occurred in the setting of underlying myocarditis. Given the patient's history, elevated troponins, and CMR results suggestive of myocarditis, we hypothesize that underlying myocarditis may have incited the development of mid-ventricular TTC. The absence of identifiable triggers in conjunction with the inferolateral ventricular wall hypokinesis and late gadolinium enhancement on CMR supports our hypothesis. The variability in clinical presentations between the present case and other reported cases of mid-ventricular TTC emphasizes the need for a deeper understanding of this condition, its triggers, and the associated clinical features to reduce the risk of future misdiagnoses. This case report highlights the significance of thorough imaging assessments for patients presenting with INOCA. Further investigations are warranted to determine underlying causes for hemodynamic instability and unique aspects of the mid-ventricular manifestation of TTC, with an emphasis on the potential association of myocarditis as an inciting factor.
我们的病例报告描述了一名疑似心肌炎患者罕见的心室中部应激性心肌病（TTC）表现。心室中部TTC是TTC的一种罕见变体，其症状和体格检查结果与急性冠状动脉综合征重叠，常导致误诊为心肌梗死。我们的病例是一名77岁女性患者，有高脂血症、右乳腺导管原位癌和憩室病病史，因胸痛放射至下颌并伴有恶心和呕吐到急诊科就诊。八个月前她有过类似发作，根据心脏导管检查结果被诊断为非阻塞性冠状动脉缺血（INOCA）。患者的父亲和祖父有心肌梗死病史，这一点值得注意。就诊时，患者血压升高，肌钙蛋白升高（最初为1058 ng/L，复查时为11421 ng/L），心电图（ECG）显示窦性心动过缓，无缺血性改变。心脏磁共振成像（CMR）显示心外膜下延迟强化，提示可能存在心肌炎，左心室下外侧壁弥漫性运动减弱，基底段和心尖段未受累。左心室功能轻度下降（射血分数为49%），出院前射血分数改善（55 - 60%）。没有室壁运动异常或明显的瓣膜疾病。该病例展示了在潜在心肌炎背景下发生的心室中部TTC的罕见表现。鉴于患者的病史、肌钙蛋白升高以及CMR结果提示心肌炎，我们推测潜在的心肌炎可能引发了心室中部TTC的发展。CMR上未发现可识别的触发因素，同时存在下外侧心室壁运动减弱和晚期钆增强，支持了我们的假设。本病例与其他已报道的心室中部TTC病例临床表现的差异强调了深入了解这种疾病、其触发因素及相关临床特征的必要性，以降低未来误诊的风险。本病例报告突出了对INOCA患者进行全面影像学评估的重要性。有必要进一步调查以确定血流动力学不稳定的潜在原因以及TTC心室中部表现的独特方面，重点是心肌炎作为激发因素的潜在关联。
