Takotsubo Cardiomyopathy Mimicking Myocardial Infarction in a Man with Myasthenic Crisis: A Case Report and Literature Review

Abstract

Takotsubo Cardiomyopathy is a syndrome characterized by transient and reversible regional myocardial dysfunction in the absence of obstructive coronary artery disease classically resulting in ventricular apical ballooning. It has a strong female predominance with onset generally in seventh decade of life, with hypothesized pathophysiology related to excess of catecholaminergic stimulation, particularly during episodes of physical or emotional stress. Takotsubo cardiomyopathy has been previously reported during myasthenic crisis, the acute deterioration of myasthenia gravis typically involving respiratory failure that is also associated with physical or emotional stress. We present the case of an atypically young male patient with classical takotsubo cardiomyopathy in the setting of myasthenic crisis after thymectomy initially concerning for ST segment elevation myocardial infarction, and a review of the literature of takotsubo cardiomyopathy in myasthenic crisis.

Defining Features of Patients who Develop Takotsubo Cardiomyopathy during Myasthenic Crisis: A Systematic Review of Case Studies

“…All studies were case reports published between 2005 and 2018. USA [8,9,10,12,18] and Asia [7,11,15,16,20] each conducted 5 studies, while 3 took place in Europe [13,14,19]. South America contributed to 1 study only [17].…”

“…5 articles did not mention any other complications [8,9,10,17,20]. Five articles emphasized a previous history of thymectomy [12] or thymoma [11,13,16,18]. The gradings for thymomas were B1 [16] or B2 [13,18].…”

“…The average age for European studies was 73.7 years. 4 articles described male patients with an average age of 64.1 years [8,12,14,17], while the remaining 10 studies of female patients had an average age of 60.5 years [7,9,10,11,13,15,16,18,19,20]. Common medical history aside from myasthenia gravis and change in thyroid function included atrial fibrillation [13,15,19] and hypertension [9,13,14].…”

“…Chest pain was only reported in 21.4% of the cases [9,17,20]. Tachycardia was recorded in 35.7% of patients [7,12,13,15,18], while only three patients presented with hypotension [7,11,17].…”

“…T-wave inversions were observed in 35.7% of patients [7,11,12,15,19], while two patients developed QT prolongation and Torsades de Pointes [15,19]. Transthoracic echocardiogram revealed apical abnormalities in all patients in the form of ballooning [9,10,11,13,15,19], dyskinesia [17], hypokinesia [7,8,12,14], akinesia [9,11,15,16,20], or sparing [10,18]. Four patients showed hyperkinetic basal function [10,11,16,20], while only one patient exhibited hypokinetic basal function [17].…”