Post-procedure rhinitis is a form of nonallergic rhinitis that is a common but underreported complication occurring after procedures requiring sedation and the use of supplemental oxygen via nasal cannula. Symptoms occur immediately after awakening from sedation and may be so unbearable, that it impairs work, daily functioning, sleep patterns, and quality of life. This case describes a 67-year-old male who developed these symptoms after esophagogastroduodenoscopy (EGD) under sedation with supplemental oxygen via nasal cannula. The proposed pathophysiology is thought to be due to the impingement of the cannula against mechanoreceptors in the nasal mucosal membrane causing parasympathetic overactivity. Based on this pathogenesis, the reported patient failed to show improvement with oral antihistamines but instead benefited from a topical anticholinergic agent. Patients at risk should be informed of the possibility of this adverse event and advised on proper treatment if it occurs.

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INTRODUCTION: Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. It is often triggered by intense physical or emotional distress, and given its low incidence may be underdiagnosed. We present an unusual case TCM with normal findings on ventriculogram. CASE PRESENTATION:A 76 year old woman with Non Hodgkin Lymphoma, presented with a 5 day history of exertional dyspnea and chest pressure. Recent stressors included the death of a sister, and social isolation from a daughter recently diagnosed with breast cancer. On presentation, vital signs were BP 179/96, HR 72bpm, RR 17, SpO2 96% on room air. Electrocardiogram revealed new Q waves in the anteroseptal leads with troponin initially <0.03 ng/ml which peaked at 0.88 ng/ml. Aspirin, atorvastatin and heparin infusion were started. Cardiac catheterization on day 2 of admission revealed nonobstructive coronaries, with estimated left ventricular ejection fraction (LVEF) of 60%, with normal wall motion. Amlodipine was started for possible coronary vasospasm, however symptomatic hypotension precluded further use. Transthoracic echocardiogram on day 3 revealed an LVEF of 35%, apical ballooning and with hypercontractile base suggestive of takotsubo cardiomyopathy. She was discharged on day 3 with optimal medical therapy.DISCUSSION: There has been increasing incidence of TCM, estimated to be 15-30 cases per 100,000 per year, although the true incidence is unknown due to possible underdiagnosis and its similarity to acute coronary syndrome (ACS). Proposed mechanisms include: multivessel coronary artery spasm, impaired cardiac microvascular function and endogenous catecholamine induced myocardial stunning and microinfarction. Typically, patients are postmenopausal women who have experienced severe, unexpected emotional stress in the prior 1 to 5 days. TCM is a diagnosis of exclusion, as most cases lack significant coronary stenosis. As such, coronary angiography is the best diagnostic study. Unless contraindicated, ventriculography is usually performed and reveals the pathognomonic apical ballooning and left ventricular dysfunction. Typically only 35-40ml of contrast is needed to diagnose TCM, however these findings were not seen in this patient's ventriculogram, even though 70ml of contrast was used. Perhaps, the delay was due to the evolution of her cardiomyopathy. Regardless, a normal ventriculogram should not rule out TCM if the diagnosis is highly suspected and further imaging should be pursued. CONCLUSIONS:Stress induced cardiomyopathy should be considered in patients with significant risk factors even in the setting of normal cardiac catheterization, echocardiogram should be performed in conjunction especially if high suspicion exists.