Takotsubo cardiomyopathy following envenomation: An updated review

Table 2 Details of diagnosis, treatment, and outcome in study participants

Ref.	Agent	Mayo criteria	Type	Mechanism	Rx	Outcome
Mishra et al[8]	Bee	Apical hypokinesia, LVEF – 40 to 45%; Absence of CAD; ST elevation, T wave inversion Troponin elevation	Apical	-Cytotoxic storm; -Direct cardiotoxic effects of bee venom; -Anaphylactic reaction	-ACEI; -BB	Improved
Aono et al[9]	Bees (Multiple)	Apical hypokinesia; Absence of CAD; ST elevation in I, II, aVl, aVf, V2 to V6 and raised Troponin	Apical			-Multi organ failure; -Death by cardiac rupture
Seecheran et al[10]	African Bee	Apical hypokinesia; Absence of CAD; ST elevation in V1, V2, V3, raised Troponin	Apical	-Cytokine storm; -Anaphylaxis	-ARNI; -Eplerenone; -Bisoprolol; -Dapagliflozin	Improved
Winogradow et al[12]	Bee	Anterior, lateral, and Posterior hypokinesia; Absence of CAD; ST elevation in VI and raised Troponin	Reverse	-	-BB; -ACEI; -Aldosterone agonist	-
Winogradow et al[12]	Bee	Apical wall hypokinesia; Absence CAD; VFIB	Apical	-Hypersensitivity; -Epinephrine Injection	-	-
Ghanim et al[11]	Bees	Basal and Mid hypokinesia; Absence of CAD; ST elevation in lateral leads and depression in anterior and inferior leads and raised Troponin	Reverse	-Catecholamine storm; -Epinephrine injection	-IABP; -VAECMO; -Adrenaline; -Norepinephrine and Dopamine	Improved
Scheiba et al[13]	Wasp	Apical and anteroseptal hypokinesia, LVEF – 45%; Absence of CAD; ST elevation in I, aVL, V2-V4 and Troponin elevation	Apical	-Hypersensitivity; -Epinephrine Injection	-BB; -ACEI; -Aspirin	Improved
Geppert et al[14]	Wasp	Apical (anterior and inferior) and anteroseptal hypokinesia (46%); Absence of CAD; ST segment elevations in the leads, V1–V3, T-negatives in leads I, aVL and V2 –V4 and raised Troponin	Apical	-Epinephrine injection	-Bisoprolol; -Ramipril; -Aspirin	Improved
Alexakis et al[16]	Black widow spider	Hypokinesis of the basal and middle segments of the LV wall with apical sparing, LVEF – 36%; CAG not done; T wave flattening in aVL, and Troponin elevation	Reverse	-Alpha-ladrotoxin mediated catecholamine storm; -Cytokine storm	- BB; -ACEI; -Aspirin; -Clopidogrel	Improved
Isbister et al[17]	Funnel web spider	Diffuse global hypokinesia with LVEF of 20%; CAG not done; Diffuse ST changes and troponin elevation	-	-Toxin; -Antivenom; -Catecholamine storm		Improved
Isbister et al[17]	Funnel web spider	Reduced EF- 45%; CAG not done; ST depression in the inferior and anterior leads and elevated troponin	-	-Toxin; -Antivenom; -Adrenaline	-	Improved
Van Rensburg et al[18]	Cape Cobra	Mid and apical LV segment hypo or akinetic, LVEF: 27%, Absent CAD; New ST elevation across anterolateral leads, subsequent EKG showing T wave inversions in anterolateral leads, raised troponin	Mid ventricular and apical; (Apical ballooning)	-Catecholamine storm; -Cytokine storm; -Catecholamine; release associated with Intensive Care Unit medication	Supportive care; Anti-snake venom administered for snake bite	Recovery of RWMA within a week (ECHO)
Murase et al[19]	Gloydius blomhoffii Snake (Mamushi)	Abnormal LV systolic function, apical akinesis, hyperdynamic basal segment of LV; No stenotic lesions noted on the CT scan; EKG changes T inversions in 1, a VL, V1-6, raised troponin	Apical	-Unknown	Supportive management; No Anti snake venom	Complete recovery (ECHO); (4 d)
Delumgahawaththa et al[40]	Unidentified (Possibly Russel Viper)	Hypokinetic mid and apex of LV segments, with ballooning, LVEF: 35%; Absence of CAD; EKG changes with ST elevation in 1 and a VL, T wave inversion II, III, a VF, V 2-6, Troponin elevation	Mid LV and Apical LV	-Catecholamine storm; -Direct myocardial toxicity; -Microvascular spasm	ACEI, BB, Diuretic, single antiplatelet, statin; Anti-snake venom	Partial recovery in 1 mo and complete in 5 mo (ECHO)
Abroug et al[29]	Androctonus australis	Patient 1: Basal ballooning of left and right ventricles; CAG not done; Troponin elevation; ST depression in four precordial leads; No other causes to explain the cardiac dysfunction. Patient 2: Impaired systolic function on echocardiogram. Basal ballooning on cardiac MRI in 24 hours; CAG not done; Troponin and ProBNP elevation; No other causes to explain the cardiac dysfunction	Basal ballooning in both patients	-Catecholamine storm; -Microvascular dysfunction	-CPAP, Dobutamine infusion; -No management mentioned	Patient 1: Discharged in 5 d, MRI in one month was normal. Patient 2: Discharged in 4 d with normal LV function on repeat echocardiography examination before discharge
Miranda et al[23]	Tityus serrulatus	Apical ballooning with hypokinesia; CAG not done; ST segment elevation in V1-V3, DI and aVL; No other causes to explain the cardiac dysfunction	Apical	-Alpha toxins act on voltage-gated sodium channels causing catecholamine storm; -Cytokine storm	-IV furosemide	Day 6 - asymptomatic, discharged; Cardiac MRI in 7 mo showed complete recovery of wall motion in apical region
Jain et al[27]	Mesobuthus tamulus	Apical, apicolateral hypokinesia; CAG not done; ST segment elevationin V1-V3 and T wave inversion; Absence of other causes of cardiac dysfunction	Apical	-Catecholamine storm; -Microvascular dysfunction	-Systemic steroids, inotropic drugs;	-Improved LVEF in 7 d; -Cerebellar infarction with clinical signs
Bianchi et al[24]	Pelagia noctiluca - A common Mediterranean jellyfish	Apical akinesis with severe left ventricular dysfunction; Absence of CAG; Acute myocardial infarction including persistent ST elevation despite thrombolysis performed for symptom relief and raised Troponin	Apical and mid-ventricular	-Direct toxicity; -Catecholamine storm; -Cytokine storm	-Symptomatic management	Improved. Completely symptom free, improved LVEF in 7 d
Tiong et al[25]	Carukia barnesi - A cubozoan/box jellyfish found in Australia	Mid-ventricular stress cardiomyopathy with apical sparing; No CAG; Persistent hyperacute T waves, rise in troponin	Mid-ventricular ballooning with apical sparing	-Sympathetic overdrive; -Catecholamine storm	-Supportive with high flow oxygen, morphine; -Magnesium sulfate IV	- Improved, discharged in 3 d

aVL: Augmented unipolar lead L; aVF: Augmented unipolar lead F; LV: Left Ventricle; LVEF: Left ventricular ejection fraction; ACEI: Angiotensin converting enzyme inhibitor; BB: Beta blocker; CAD: Coronary artery disease; CAG: Coronary angiogram; ARNI: Angiotensin receptor-neprilysin inhibitor; VFIB: Ventricular fibrillation; ECHO: Echocardiography; EKG: Electrocardiogram; IV: intravenous; RWMA: Regional wall motion abnormality; CT: Computed tomography; MRI: Magnetic resonance imaging; CPAP: Continuous positive airway pressure; Pro BNP: Pro brain natriuretic peptide; IABP: Intra-aortic balloon pump; VAECMO: Veno-arterial extra corporeal membrane oxygenation.