Abstract
IntroductionMyasthenia gravis is a neuromuscular junction post-synaptic autoimmune disorder. Myasthenic crisis is characterized by respiratory failure requiring mechanical ventilation. Takotsubo cardiomyopathy is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease.Case presentationWe report a unique case of a 60-year-old Hispanic woman with myasthenia gravis who developed takotsubo cardiomyopathy and concomitant myasthenic crisis that appear to have been triggered by a stressful life event. On admission, she presented with severe mid-sternal chest pain and shortness of breath shortly after a personally significant stressful life event. A pertinent neurological examination showed bilateral facial weakness and right ptosis. The left ventriculogram showed apical ballooning with hyperdynamic proximal segments with sparing of the apex. Her troponin I level was elevated, while cardiac catheterization revealed no significant coronary artery disease. The findings were consistent with takotsubo cardiomyopathy. Shortly after cardiac catheterization, she developed bilateral ophthalmoparesis and significant bulbar and respiratory muscle weakness. Forced vital capacity values were persistently less than 1 L. The patient developed respiratory failure and required endotracheal intubation. After plasmapheresis and corticosteroid treatment, her clinical course improved with successful extubation. A normal left ventricle chamber size and a normal ejection fraction were noted by an echocardiogram repeated 10 months later.ConclusionThis is the first reported case of the simultaneous triggering of both takotsubo cardiomyopathy and myasthenic crisis by the physiologic consequences of a state of severe emotional stress. We hypothesize that the mechanism underlying the rare association of takotsubo cardiomyopathy with myasthenic crisis involves excessive endogenous glucocorticoid release, a high-catecholamine state, or a combination of both. We advocate careful cardiac monitoring of myasthenia gravis patients during acute emotional or physical stress, as there is potential risk of developing takotsubo cardiomyopathy.
Highlights
Myasthenia gravis is a neuromuscular junction post-synaptic autoimmune disorder
We hypothesize that the mechanism underlying the rare association of takotsubo cardiomyopathy with myasthenic crisis involves excessive endogenous glucocorticoid release, a high-catecholamine state, or a combination of both
We present a case of takotsubo cardiomyopathy (TC) that appears to have been related to a stressful life event that was believed to have triggered a concomitant Myasthenia gravis (MG) crisis
Summary
Alterations in corticosteroid and/or catecholamine in response to acute and chronic stressors are speculated to have played a key role in the development of MG exacerbation and TC in our patient. We advocate careful cardiac monitoring of MG patients during acute emotional or physical stress, as there is a potential risk of developing TC. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Doi:10.1186/1752-1947-4-393 Cite this article as: Beydoun et al.: Emotional stress as a trigger of myasthenic crisis and concomitant takotsubo cardiomyopathy: a case report. Author details 1Department of Neurology, University of Southern California, Los Angeles, California, USA. JTW analyzed and interpreted the patient’s data and was a major contributor in writing the manuscript. AF is a cardiologist who analyzed and interpreted the patient’s data regarding cardiac symptoms and contributed to writing and review of the manuscript. RLL analyzed and interpreted the patient’s data relative to MG symptoms and contributed to writing the manuscript. Competing interests The authors declare that they have no competing interests
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