P46 Takotsubo cardiomyopathy in a GPA patient receiving rituximab therapy

Abstract

Abstract Background Cardiac involvement in GPA is quite rare. Patients with GPA are two times more likely to die of cardiovascular complications as compared to the general population due to accelerated atherosclerosis. Cardiac involvement in GPA is secondary to necrotising vasculitis with granulomatous infiltrates, usually resulting in coronary artery thrombosis. We present a case of Takotsubo cardiomyopathy in a patient of GPA treated with rituximab. There has previously only been one case report of a patient on rituximab therapy developing Takotsubo cardiomyopathy. Methods This 67-year-old woman was diagnosed with GPA in January 2018 when she presented with a necrotic lung lesion along with nasal crusting and leg ulcers. Her ANCA was 102 i.u./ml at the time. We treated with cyclophosphamide and azathioprine to good effect. Then she had a relapse six months later and presented to the hospital with stridor due to subglottic stenosis. At this point we switched to rituximab and methotrexate to induce remission, her ANCA titres settled to 3.4 i.u./ml at this point. After her second cycle of rituximab, she presented to the hospital with shortness of breath, chest pain and stridor in November 2018. Results At her presentation with chest pain in November 2018, an ECG was performed, which showed an incomplete LBBB with ST elevation in anterior leads with a troponin level of 550ng/ml. A repeat ECG after 2 hours, showed ST elevations in anterolateral leads with a troponin level of 1259ng/ml. We treated this as an acute myocardial infarction. An echocardiogram was obtained, which was remarkable in that it showed no new regional wall motion abnormalities. A subsequent coronary angiogram confirmed that there was no coronary artery disease raising the possibility of Takotsubo cardiomyopathy. Conclusion Rituximab is implicated in cardiac arrhythmia and coronary vasospasm during the infusion, reduction in LVEF, non-ischaemic cardiomyopathy, cardiogenic shock after. Our patient had a myocardial infarction with normal coronaries, and she was going through a very emotionally stressful period with her husband’s illness at the time of her presentation, which makes Takatsubo cardiomyopathy a very likely diagnosis. There are few case reports in the literature and, clinicians should be aware of this rare complication. Disclosures S.P. Jayanti None. S. Nair None. D. Makkuni None.