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INTRODUCTION: Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. It is often triggered by intense physical or emotional distress, and given its low incidence may be underdiagnosed. We present an unusual case TCM with normal findings on ventriculogram. CASE PRESENTATION:A 76 year old woman with Non Hodgkin Lymphoma, presented with a 5 day history of exertional dyspnea and chest pressure. Recent stressors included the death of a sister, and social isolation from a daughter recently diagnosed with breast cancer. On presentation, vital signs were BP 179/96, HR 72bpm, RR 17, SpO2 96% on room air. Electrocardiogram revealed new Q waves in the anteroseptal leads with troponin initially <0.03 ng/ml which peaked at 0.88 ng/ml. Aspirin, atorvastatin and heparin infusion were started. Cardiac catheterization on day 2 of admission revealed nonobstructive coronaries, with estimated left ventricular ejection fraction (LVEF) of 60%, with normal wall motion. Amlodipine was started for possible coronary vasospasm, however symptomatic hypotension precluded further use. Transthoracic echocardiogram on day 3 revealed an LVEF of 35%, apical ballooning and with hypercontractile base suggestive of takotsubo cardiomyopathy. She was discharged on day 3 with optimal medical therapy.DISCUSSION: There has been increasing incidence of TCM, estimated to be 15-30 cases per 100,000 per year, although the true incidence is unknown due to possible underdiagnosis and its similarity to acute coronary syndrome (ACS). Proposed mechanisms include: multivessel coronary artery spasm, impaired cardiac microvascular function and endogenous catecholamine induced myocardial stunning and microinfarction. Typically, patients are postmenopausal women who have experienced severe, unexpected emotional stress in the prior 1 to 5 days. TCM is a diagnosis of exclusion, as most cases lack significant coronary stenosis. As such, coronary angiography is the best diagnostic study. Unless contraindicated, ventriculography is usually performed and reveals the pathognomonic apical ballooning and left ventricular dysfunction. Typically only 35-40ml of contrast is needed to diagnose TCM, however these findings were not seen in this patient's ventriculogram, even though 70ml of contrast was used. Perhaps, the delay was due to the evolution of her cardiomyopathy. Regardless, a normal ventriculogram should not rule out TCM if the diagnosis is highly suspected and further imaging should be pursued. CONCLUSIONS:Stress induced cardiomyopathy should be considered in patients with significant risk factors even in the setting of normal cardiac catheterization, echocardiogram should be performed in conjunction especially if high suspicion exists.
The formation of a bronchopleural fistula (BPF) is a rare but known complication following major thoracic surgery. In a study by Nachira et al. looking at 835 patients in Italy who underwent major lung resection, 786 patients underwent lobectomy with 11 (1.3%) developing a BPF [1]. In other studies their incidence has been reported between 0.5-3% [2]. Here we present a case of an unusual presentation of this rare complication.CASE PRESENTATION: 73 y.o F former smoker was incidentally found to have right upper lobe (RUL) chondral myxoid tumor. She underwent bronchoscopy and video assisted thoracoscopy (VATS) with wedge resection of RUL and placement of chest tube without peri-operative complications. Later that day, rapid response was called as patient developed facial swelling, sensation of throat tightening and upper chest erythema with subcutaneous emphysema (SCE) (Figure 1). Initial thought was possible anaphylaxis from NSAIDs and treated as such. Patient later further deteriorated leading to intubation and transfer to the ICU. Second right-sided chest tube and skin holes placed on chest for relief of subcutaneous air. Patient was extubated next day. Due to persistent SCE (Figure 2) and need for respiratory support, patient received bilateral blow-holes and was downgraded to surgical floor after improvement. Symptoms again recurred requiring re-intubation. Blow-holes were extended and 3rd right-sided chest tube placed. She was taken for repeat VATS and found to have a BPF with adhesions. Lysis of adhesions was performed with RUL mediastinal drainage and mechanical pleural abrasion. The rest of patient's hospital course was uncomplicated with eventual removal of chest tubes and discharge.DISCUSSION: As discussed, our patient had a complicated post-operative course, complicated further by the unique presentation of her BPF. We found no previous literature or case reports illustrating similar presenting symptoms of BPFs. They typically present 1 -12 weeks postoperatively [2]. Our patient did not fit this timeline and had a very atypical presentation which mimicked symptoms of an anaphylactoid reaction. Although diffuse subcutaneous emphysema has been a reported finding from BPFs [3], this was thought to be a normal result of recent surgical procedure. This uncommon presentation led to delay in appropriate management and extended hospital course for this patient.CONCLUSIONS: This case demonstrates a unique presentation of a potentially fatal complication of major thoracic surgeries. BPF formation may need to be considered in patients who present similarly in the future.
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