Dear Editor, Takotsubo Cardiomyopathy (TTC), first described in 1991 in Japan, is a condition that closely resembles ACS in symptoms, laboratory values, and EKG findings and results in acute LV dysfunction, but yet differs in that it is without evidence of coronary artery stenosis on angiography and presents after intense emotional or physical stress (1-4). Mayo clinic has proposed several criteria for the diagnosis of TTC and it includes the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture as an essential component in the definition. A few case reports have described the association between TTC and anorexia nervosa, but the exact pathophysiology has never fully been elucidated.We present a 34-year-old woman with past medical history of anorexia nervosa presented to our facility non-responsive and hypoglycemic (blood sugar of 49). She was found to have decreased respiratory rate, hypotension, and tachycardia and accordingly she was admitted for possible narcotic overdose. Naloxone and dextrose were administered to the patient on the scene. Due to her continued altered mental status she was intubated for airway protection and transferred to the Medical ICU.On arrival to the ICU, her initial EKG showed ST depression with T wave inversion in the inferolateral leads, in addition to Q waves in the anteroseptal leads (V1-V3). The first set of troponins was elevated at 1.2 ng/ml and trended to 1.94 ng/ml 4 hours later. Cardiology was consulted and limited bedside Echo was obtained which showed poor Ejection Fraction with global hypokinesis and possible cardiomyopathy. No regional wall motion abnormalities were seen. Midodrine was started for maintenance of blood pressure. A working diagnosis of Stress Induced Cardiomyopathy was made, but other possibilities including vitamin B1 deficiency (beri-beri) were considered. Lab values were significant for pancytopenia, which was attributed to her severe nutritional deficiency. As the patient was symptomatically improved, standard 2-D Echocardiogram was done and showed an EF of 15-20% with global hypokinesis except for the basal segment which was hyperkinetic, a finding consistent with Stress Induced Cardiomyopathy (SCM), also known as Takotsubo Cardiomyopathy (TTC). This finding was confirmed later by a strain analysis of the echocardiographic images (figure 1).Four days later, patient was transferred to the medical floor. Her nutrition was optimized. Patient electrolytes were monitored on daily basis for the concern of refeeding syndrome. A repeat TTE was done (7 days after the first TTE) to rule out endocarditis.The study failed to demonstrate vegetations, but was significant for 0.8 cm loosely organized left ventricular apical thrombus. Interestingly, the EF was improved to 25-30%. Given the LV thrombus, the patient was started on Warfarin. Enoxaparin was held as the patient was surprisingly thrombocytopenic (platelet 24,000/mm3) despite the left ventricle mural thrombus.Despite her improvement, the patient became dyspneic and the Ch...

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