Takotsubo Cardiomyopathy Triggered by Influenza A Virus

Abstract

We herein report the first case of Takotsubo cardiomyopathy triggered by influenza A virus. Myocardial involvement in influenza virus infection has been described in 10% of cases. The literature has principally reported cases of acute myocarditis ranging from asymptomatic to fulminant heart failure and cardiac tamponade. Takotsubo cardiomyopathy frequently occurs in the setting of significant emotional or physical stress or acute medical illness, with a predominance in postmenopausal women. We report the diagnosis, management and outcomes presented in this case, with the aim of describing a new cardiovascular complication of influenza virus infection. Case ReportA 57-year-old woman presented to the emergency department for pulmonary edema requiring oro-tracheal intubation. She had developed hyperthermia with a temperature of 39 2 days prior to presentation. An electrocardiogram showed ST-segment elevation in leads V3, V4 and V5 (Fig. 1). Laboratory testing revealed an increased troponin I-C level (TnI-C: 0.52 μg/mL, n<0.04 μg/mL) and a normal rate of creatine kinase (116 UI/L initially and 113 UI/L the 24 hours later, n<145 UI/L) (Fig. 1). Her medical history consisted of chronic respiratory failure with oxygen dependency in the context of chronic obstructive pulmonary disease and Takotsubo syndrome 10 years previously. There was no information regarding pheochromocytomas or cerebrovascular disease in her history.Because of suspected acute coronary syndrome, the patient was administered aspirin 250 mg and bivalirudin, both intravenously. She developed severe hypotension requiring intravenous administration of norepinephrine. She was transferred to the catheterization laboratory for emergency cardiac coronary angiography, which showed no significant atherosclerosis. The left ventricular angiogram revealed typical apical ballooning (Fig. 2). Echocardiography demonstrated mid-ventricular and apical akinesia with depressed left ventricular function and an estimated ejection fraction of 30%. The patient was monitored using a pulse index continuous cardiac output (PICCO) device and continuous central venous oxygenation (ScVO2) measurements. The first hemodynamic measurement yielded the following results under norepinephrine treatment (2 μg/kg/min): mean arterial pressure (MAP): 65 mmHg; cardiac index (CI): 1.54 L/min/ m 2 ; ScVO2: 55%, cardiac function index: 2 L/min. The lactate level measured was 7 mmol/L with severe metabolic acidosis (pH 7.15). A multidisciplinary discussion precluded the use of extra corporeal membrane oxygenation (ECMO). Therefore, despite the presence of Takotsubo syndrome, 3 μg/kg/min dobutamine was initiated. Under this therapy, the cardiac function and ScVO2 increased, and the peripheral signs of shock disappeared. Eighteen hours later, echocardiography revealed total restoration of ventricular function. The number of eosinophils and other white blood cells were normal during hospitalization. Influenza A (H1N1) virus infection was diagnosed by a nasal rapid influenza diagnostic test...

Immune Mechanisms in Cardiovascular Diseases Associated With Viral Infection

“…Several reports have shown Takotsubo cardiomyopathy in COVID-19 patients (180)(181)(182)(183)(184)(185). Correspondingly, this condition is also reported in influenza-infected patients (186)(187)(188)(189). These reports suggest that cardiomyopathy, especially stress-induced cardiomyopathy is reported in influenza viral infected and COVID-19 patients.…”

Coronavirus: the geriatric emergency of 2020. Joint document of the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology

“…33,36,37 Clinical signs of heart failure are frequent in patients hospitalized for COVID-19 (up to 29% in some of the published series), which could be due both to decompensation of a pre-existing disease and to the development of myocarditis or stress cardiomyopathy. 8,38 Heart failure increases mortality and can also confound suspicion of COVID-19 infection in patients who attend emergency departments with dyspnea. It is unknown if the infection is associated with coronary heart disease, but there is evidence that patients with respiratory infections have an elevated risk of acute myocardial infarction, probably due to atherosclerotic plaque destabilization.…”

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic

“…Notably, heart failure was more commonly observed than acute kidney injury in this cohort and was more common in patients who did not survive the hospitalization compared to those who did survive (51.9% vs. 11.7%). Whether heart failure is most commonly due to exacerbation of pre-existing left ventricular dysfunction versus new cardiomyopathy (either due to myocarditis or stress cardiomyopathy) remains unclear (53). Right heart failure and associated pulmonary hypertension should be also considered, in particular in the context of severe parenchymal lung disease and ARDS.…”