Onset of Takotsubo Syndrome during the Clinical Course of Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Report

Abstract

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic vasculitis resulting in severe organ injuries. ANCA is a disease-labeled antibody of AAV, and myeloperoxidase (MPO) and proteinase 3 are the main targeted antigens of ANCA. Takotsubo syndrome, a transient cardiac dysfunction caused by emotional or physical stress, is characterized by ST-segment elevation and negative T waves in electrocardiogram, transient left ventricular asynergy, and absence of obstructive coronary disease. To the best of our knowledge, only two cases of coexistence of AAV and takotsubo syndrome have been reported. Herein, we report the case of AAV complicated with takotsubo syndrome. A 78-year-old Japanese woman presented with severe renal dysfunction, which was diagnosed as MPO-ANCA-associated systemic vasculitis. Despite the treatment with cyclophosphamide and glucocorticoid, the patient presented with severe respiratory failure due to alveolar hemorrhage and heart failure. Electrocardiography indicated newly developed T wave inversions. Echocardiography demonstrated severe left ventricular dysfunction with hypokinesis of the apical area. Moreover, coronary angiography revealed no noticeable stenotic or obstructive lesions. These findings indicate the onset of takotsubo syndrome. After immunosuppressive therapy, systemic vasculitis and takotsubo syndrome were improved. Although a coexisting case of AAV and takotsubo syndrome is rare, we have to consider the possible complication of takotsubo syndrome in case of presenting acute heart failure. Considering the present case and the previously reported coexisting cases of takotsubo syndrome and AAV, we propose that female sex, initiation of glucocorticoid therapy, and high titer of MPO-ANCA are potential risk factors of developing takotsubo syndrome.

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases

“…Among females, the median age was 60, with an IQR of 43–70. Males had a slightly lower median age [ 58 ] with a wider IQR of 30–76 years. There was a strong female predominance, with a female-to-male ratio of around 5.3 to 1.…”

Cardiopulmonary arrest due to bronchoscopy-induced Takotsubo syndrome in a patient with antineutrophil cytoplasmic autoantibody-associated lung disease: a case report

“…The incidence of TTS was shown to be 10 times higher in hospitalized patients with systemic sclerosis, in which macrophage activation plays an important role in multiple organ fibrosis than in the general inpatient population 8 , 9 ) . In addition, three cases of TTS that developed during the clinical course of AAV have been reported 10 ) . Similar to our patient, all three patients were women aged over 70 years who were receiving glucocorticoid therapy.…”