Myasthenic crisis and Takotsubo syndrome: a non-chance relationship
*Correspondencia: Dr. Sergio Mayor Gómez. Servicio de Neurología. Hospital de Navarra. Complejo Hospitalario de Navarra. Irunlarrea, 3. E-31008 Pamplona (Navarra).
Fax: +34 848 422 303.
E-mail: sergiomirneurologia@hotmail.com
INTRODUCTION. Takotsubo syndrome (TTS) is a rare condition that mimics an acute myocardial infarction. It is associated with precordial pain, ST segment elevation, absence of coronary occlusion and reversible deformation of the left ventricle due to anteroapical dyskinesia that is reminiscent of a Japanese art of fishing octopuses (tako-tsubo). It is related with emotional and physical stress, and is thought to be mediated by an acute release of catecholamines. CASE REPORT. An 83-year-old woman with hypertension. She was admitted to the heart unit with a suspected acute coronary syndrome and respiratory failure, and thus required mechanical ventilation. An echocardiography scan showed severe ventricular dysfunction with apical dyskinesia. Cardiac catheterisation ruled out heart disease and a ventriculography scan revealed a bloated systolic deformation of the anterior and apical segments (TTS). Attempts to withdraw ventilation were unsuccessful and the neurology department was consulted. A directed medical history revealed that the patient had been suffering from generalised weakness, and progressive dysphagia and dyspnoea for several months. Results of an edrophonium test were positive. Single-fibre electromyography showed a pathological jitter and acetylcholine anti-receptor antibodies were positive. The patient was treated with immunoglobulins, corticoids and pyridostigmine. A control echocardiogram showed resolution of the TTS. CONCLUSIONS. TTS must be considered within the extra-neurological complications arising from myasthenic crisis. The neurologist must take this into account when faced with any symptom or sign of a potentially cardiac origin in myasthenic crisis and other neurocritical conditions.
Caso clínico Mujer de 83 años, hipertensa. Ingresó en la unidad coronaria con sospecha de síndrome coronario agudo e insuficiencia respiratoria, por lo que requirió ventilación mecánica. El ecocardiograma mostró disfunción ventricular grave con discinesia apical. El cateterismo cardíaco descartó enfermedad coronaria. La ventriculografía reveló una deformación ampulosa sistólica de los segmentos anterior y apical (STT). Se intentó retirar la ventilación sin éxito y se consultó con neurología. La anamnesis dirigida reveló un cuadro de meses de evolución de debilidad generalizada, disfagia y disnea progresivas. Un test de edrofonio fue positivo. El electromiograma de fibra aislada mostró jitter patológico. Los anticuerpos antirreceptor de acetilcolina fueron positivos. La paciente fue tratada con inmunoglobulinas, corticoides y piridostigmina. El ecocardiograma de control objetivó resolución del STT.
Conclusiones El STT debe contemplarse dentro de las complicaciones extraneurológicas de la crisis miasténica. El neurólogo debe tenerlo presente ante cualquier síntoma o signo de potencial origen cardíaco en la crisis miasténica y otros padecimientos neurocríticos.
