Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jan 26, 2021; 13(1): 21-27
Published online Jan 26, 2021. doi: 10.4330/wjc.v13.i1.21
Myasthenic crisis-induced Takotsubo cardiomyopathy in an elderly man: A case report of an underestimated but deadly combination
Yvonne Kuo, Thomas H Ottens, Ivo van der Bilt, Ruud WM Keunen, Sakir Akin
Yvonne Kuo, Thomas H Ottens, Sakir Akin, Intensive Care Unit, Hagaziekenhuis, The Hague 2545, Netherlands
Ivo van der Bilt, Department of Cardiology, Hagaziekenhuis, The Hague 2545, Netherlands
Ruud WM Keunen, Department of Neurology, Haga Teaching Hospital, The Hague 2545, Netherlands
Author contributions: Kuo Y, Ottens TH and Akin S wrote the original draft of the paper; Kuo Y, Ottens TH, van der Bilt I, Keunen R and Akin S were involved in the management of this patient, contributed to revising and editing of the manuscript, and served in project administration; Ottens TH and Akin S supervised the project; All authors read and approved the final manuscript.
Informed consent statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Conflict-of-interest statement: The authors declare that they have no competing interests.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sakir Akin, MD, PhD, Doctor, Staff Physician, Intensive Care Unit, Hagaziekenhuis, Els Borst-Eilersplein 275 2545 AA The Hague, The Hague 2545, Netherlands. s.akin@hagaziekenhuis.nl
Received: August 17, 2020
Peer-review started: August 17, 2020
First decision: November 16, 2020
Revised: November 30, 2020
Accepted: December 13, 2020
Article in press: December 13, 2020
Published online: January 26, 2021
Abstract
BACKGROUND

Patients with myasthenia gravis (MG) are at a higher risk of developing Takotsubo cardiomyopathy (TTC), particularly during a myasthenic crisis. Myasthenic crisis-associated TTC occurs predominantly in women. In this case report, we present a man with metastasized prostate carcinoma who developed TTC after new-onset MG.

CASE SUMMARY

An 81-year-old man with non-insulin dependent diabetes mellitus and metastasized prostate carcinoma presented with dyspnea. During primary assessment examination at the emergency department, there was evident blepharoptosis of his right eye. His electrocardiograms were suggestive of an acute anterior wall myocardial infarction, for which he underwent emergency coronary angiography. No obstructive coronary artery disease was found. During the coronary angiography, the patient developed respiratory failure and was admitted to the Intensive Care Unit for non-invasive respiratory support. The following day, diagnostic neostigmine test revealed a myasthenic crisis. Bedside echocardiography revealed left ventricular apical ballooning with a typical appearance of TTC. Despite the potentially reversible character of both MG and TTC, the patient and family requested an end of support in the Intensive Care Unit due to age and chronic malignancy with reduced quality of life in recent months after non-chemo-responding prostate carcinoma. The patient died soon after treatment withdrawal.

CONCLUSION

Elderly men should be carefully evaluated for TTC when new-onset MG is diagnosed.

Keywords: Takotsubo cardiomyopathy, Broken heart syndrome, Stress-induced cardiomyopathy, Myasthenic crisis, Respiratory failure, Case report

Core Tip: An elderly man presented with dyspnea and neurological symptoms, including blepharoptosis. Simultaneously, the patient had signs of an acute myocardial infarction, but obstructive coronary artery disease was ruled out by coronary angiogram. Due to respiratory failure, the patient was admitted to the Intensive Care Unit for non-invasive support. The next day, bedside echocardiography revealed left ventricular apical ballooning, typical for Takotsubo cardiomyopathy. Meanwhile, second consultation by the neurologist performing a diagnostic neostigmine test confirmed a myasthenic crisis. Altogether, the patient was diagnosed with a new-onset myasthenic crisis-induced Takotsubo cardiomyopathy. Unfortunately, in this elderly man, this combination was fatal.