Ischemic cerebrovascular stroke as complication of sepsis-induced Takotsubo cardiomyopathy

Abstract

A 61-year-old woman presented to our emergency department with diarrhea and vomiting, and was treated with ciprofloxacin for suspected gastroenteritis. After 1 day she developed dyspnea and fever. Chest radiography revealed bilateral infiltrates, and the patient was then treated empirically with ceftriaxone and clarithromycin for community acquired pneumonia. At hospital day 3, septic shock developed. She was tachycardic with a heart rate of 150 beats per minute, tachypneic with a respiratory rate of 40 breaths per minute, and hypoxemic with an oxygen saturation of 84%. The blood lactate was 3.5 mmol/L. She was transferred to the intensive care unit (ICU), and early goal directed therapy was initiated with aggressive volume resuscitation, vasopressor, and inotropic support. With oxygen delivery via a face mask, adequate oxygenation was achieved so that mechanical ventilation could be avoided. The antibiotic therapy was broadened to cefepime and clarithromycin. On hospital day 4, laboratory tests showed elevation of the serum troponin T to 2.9 ng/mL. Clinically, the patient had no chest pain. The ECG showed new T-wave inversions in the inferior and antero-apical leads. An echocardiography revealed an impaired left ventricular ejection fraction of 30% with akinetic apical and anteroseptal walls, while the basal and lateral walls were hyperkinetic. The patient underwent coronary angiography in which no relevant coronary artery stenosis was found. The ventriculography showed contraction of only basal parts of the left ventricle, suggesting Takotsubo cardiomyopathy. The patient was treated with antithrombotic therapy. No intraventricular thrombus was seen at that time. After cardiopulmonary recompensation, the patient was