Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Abstract

Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial symptoms and underscores the importance of rapidly recognizing this disorder.Keywords Postpartum cardiomyopathy Á Neuropathy Á Rhabdomyolysis Case reportA 22-year-old woman was referred from another hospital to our department of neurology because of severe rhabdomyolysis (CK levels of [13,000 U/l) and muscle weakness of both legs. Five days before admission she suffered from acute muscle cramps, followed by muscle weakness in both legs and numbness of both feet. Her medical history revealed preeclampsia 1 month earlier and she delivered a healthy baby 3 weeks before presentation. She used folic acid and ferrofumarate because of the recent pregnancy and nitrofurantoine because of a urinary tract infection. She did not smoke and used no alcohol. Neurological examination revealed a paresis of the anterior tibial and extensor hallucis longus muscles on both sides (left [ right). There was sock-shaped hyposensibility without pain. Both feet were warm and had a normal color. The right leg was edematous and arterial pulsations were absent in the right foot. Electromyography showed multiple neuropathies in distal branches of the left peroneal, posterior tibial, sural and superficial peroneal nerves. Muscle biopsy revealed no abnormalities. On angiography of the legs thrombosis of the right internal iliac artery, the right proximal superficial femoral artery (AFS), the left AFS, popliteal and anterior tibial arteries was observed as well as an infarction of the right kidney (Fig. 1). The chest X-ray showed a widened mediastinum and echocardiography revealed a decreased left ventricular function (ejection fraction 30%). No thrombophilic risk factors were found and there was no evidence for an autoimmune disease (normal levels of homocysteine, antithrombin, protein C and S, factor V mutation, prothrombin mutation, lupus anticoagulant, anticardiolipin, ANA, ANCA, complement C3 and C4 all negative). Based on a cardiomyopathy in the context of her recent pregnancy, postpartum cardiomyopathy (PPCM) was diagnosed. Later, when asked for earlier symptoms of cardiomyopathy, the patient mentioned that she had been progressively dyspnoeic in the last weeks of her pregnancy. Thrombectomy of the occluded arteries was performed and anticoagulation (low molecular weight heparin) was started. Thereafter the patient was treated with a vitamin K antagonist, acetylsalicylic acid and an ace-inhibitor. After 8 months the patient had only mild neuropathic pain in her left foot, which responded well to gabapentin. Her heart