Takotsubo cardiomyopathy following lightning strike

Abstract

Lightning strike is the most common environmental cause of sudden cardiac death, but may also be associated with a myriad of injuries to various organ systems. Direct myocardial injury may be manifest as electrocardiographic alterations or elevation in cardiac-specific isoenzymes; however, significant electrical cardiac trauma appears uncommon. A case is presented of severe acute cardiomyopathy in a "Takotsubo" distribution causing cardiogenic shock following lightning strike in a previously healthy 37-year-old woman. Although rarely identified in this context, Takotsubo cardiomyopathy (also known as "transient left ventricular apical ballooning syndrome") is characterised by transient cardiac dysfunction, electrocardiographic changes that may mimic acute myocardial infarction and minimal release of cardiac-specific enzymes in the absence of obstructive coronary artery disease. The condition is associated with a substantial female bias (up to 90% of cases) in reported series, and despite occasionally dramatic presentations recovery of left ventricular function is almost universal over days to weeks. In rare instances, however, the syndrome has been associated with more catastrophic complications such as papillary muscle or cardiac free wall rupture, necessitating emergency surgical intervention to preserve life. In clinical practice, non-lethal lightning strike-induced cardiac injury is frequently associated with small elevations of cardiac isoenzymes without overt clinical sequelae; however, the incidence of silent myocardial mechanical dysfunction remains unknown. Cases such as the one presented highlight the potential for serious, albeit usually transient, cardiac sequelae from lightning strike injury and remind us that our mothers' advice to remain indoors during thunderstorms is probably worth heeding.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

“…Physical stressors may be related to physical activities (for instance heavy gardening 157 or sports 158 ), medical conditions, or procedures such as acute respiratory failure (e.g. asthma, 159 end-stage chronic obstructive lung disease 160 ), pancreatitis, 161 cholecystitis, 162 pneumothorax, 163 traumatic injury, 164 sepsis, 165 thyrotoxicosis, 166 malignancy also including chemotherapy 167 and radiotherapy, 168 pregnancy, 169 Caesarean section, 170 lightning strike, 171 near drowning, 172 hypothermia, 173 cocaine, 174 alcohol 175 or opiate withdrawal, 176 and carbon-monoxide poisoning. 177 Exogenous drugs in terms of catecholamines 56 , 178 and sympathomimetic drugs 56 , 179 may also act as triggers for TTS including dobutamine stress testing, 180 electrophysiological testing 181 (with isoproterenol or epinephrine) and beta-agonists for asthma or chronic obstructive lung disease.…”

Takotsubo Cardiomyopathy: A Unique Cardiomyopathy With Variable Ventricular Morphology

“…Commonly reported precipitating stressors include being informed of the death of a loved one, social events such as public speaking or a surprise birthday party, and anxiety or pain related to a medical procedure (1)(2)(3)(4)(5)(6)9). Other situations that are less common, but still considered possible triggers of takotsubo cardiomyopathy, include cocaine use (13), opiate withdrawal (14), stress testing (15) (with dobutamine [16]), lightning strike (17), ergonovine injection (18), and thyrotoxicosis (19). A chronobiological pattern has also been reported by a multicenter Italian study, with increased frequency of presentation in the summer months and in the morning hours (20).…”

Myocardial Stunning After Electrocution With Complete Reversibility Within 24 Hours: Role of Repeat Transthoracic Echocardiograms in Potential Cardiac Transplant Donors

“…Other cardiac effects include myocardial necrosis, hemorrhagic pericarditis and coronary vasospasm resulting in myocardial infarction [ 11 ]. Table 1 [ 10 - 15 ] describes the various cardiac effects of electrical injury reported in the literature. Electrical injury can also lead to myocardial stunning in the absence of reversible myocardial injury, the exact mechanism of which is unknown [ 11 ].…”