A Case Report of Recurrent Takotsubo Cardiomyopathy in a Patient during Myasthenia Crisis

Abstract

Introduction Patients with myasthenia crisis can develop Takotsubo stress cardiomyopathy (SC) due to emotional or physical stress and high level of circulating catecholamines. We report a patient who developed recurrent Takotsubo cardiomyopathy during myasthenia crisis. Coexisting autoimmune disorders known to precipitate stress cardiomyopathy like Grave's disease need to be evaluated. Case Report A 69-year-old female with seropositive myasthenia gravis (MG), Grave's disease, and coronary artery disease on monthly infusion of intravenous immunoglobulin (IVIG), prednisone, pyridostigmine, and methimazole presented with shortness of breath and chest pain. Electrocardiogram (ECG) showed ST elevation in anterolateral leads with troponemia. Coronary angiogram was unremarkable for occlusive coronary disease with left ventriculogram showing reduced wall motion with apical and mid left ventricle (LV) hypokinesis suggestive of Takotsubo stress cardiomyopathy. Her symptoms were attributed to MG crisis. Her symptoms, ECG, and echocardiographic findings resolved after five cycles of plasma exchange (PLEX). She had another similar episode one year later during myasthenia crisis with subsequent resolution in 10 days after PLEX. Conclusion Takotsubo cardiomyopathy can be one of the manifestations of myasthenia crisis with or without coexisting Grave's disease. These patients might benefit from meticulous fluid status and cardiac monitoring while administering rescue treatments like IVIG and PLEX.

Defining Features of Patients who Develop Takotsubo Cardiomyopathy during Myasthenic Crisis: A Systematic Review of Case Studies

“…All studies were case reports published between 2005 and 2018. USA [8,9,10,12,18] and Asia [7,11,15,16,20] each conducted 5 studies, while 3 took place in Europe [13,14,19]. South America contributed to 1 study only [17].…”

“…All studies described patients who were admitted for myasthenic crisis who then developed Takotsubo cardiomyopathy. 5 articles did not mention any other complications [8,9,10,17,20]. Five articles emphasized a previous history of thymectomy [12] or thymoma [11,13,16,18].…”

“…4 articles described male patients with an average age of 64.1 years [8,12,14,17], while the remaining 10 studies of female patients had an average age of 60.5 years [7,9,10,11,13,15,16,18,19,20]. Common medical history aside from myasthenia gravis and change in thyroid function included atrial fibrillation [13,15,19] and hypertension [9,13,14]. Grave’s disease [9] and polymyalgia rheumatica [14] were reported affecting 1 patient each.…”

“…Common medical history aside from myasthenia gravis and change in thyroid function included atrial fibrillation [13,15,19] and hypertension [9,13,14]. Grave’s disease [9] and polymyalgia rheumatica [14] were reported affecting 1 patient each.…”

“…The next common presentation was generalized weakness and fatigue (71.4%) [7–11,14,16,17,19,20] followed by dysphagia (57.1%) [7 ,8,9,10,14,15,18,19] and then equally ocular problems involving either ptosis or diplopia [7,8,9,10,16,19] or dysarthria (42.9%) [7,8,9,13,14,19]. Chest pain was only reported in 21.4% of the cases [9,17,20]. Tachycardia was recorded in 35.7% of patients [7,12,13,15,18], while only three patients presented with hypotension [7,11,17].…”