Case presentation
A 56-year-old African American male with medical history significant for Hypertension, Hyperlipidemia, and alcohol dependence who presented with incoherent speech with altered mentation. He reported dyspnea with mild exertion. He denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, or pedal swelling. He has been binge drinking several cans of beer, about 24 of 24 -Oz can, prior to presentation. This was, following, a sudden incarceration and imprisonment of his wife. Patient had his last drink 5 hours prior to presentation to the Emergency room.
Examination revealed a disheveled middle age African American male who was confused and inebriated. His Vital signs revealed blood pressure 129/67mmHg, pulse 73beats/minute, and body temperature 99.4F. He was somnolent but easily arousable, and oriented to person, place but not to time or situation. Neurologic examination showed no focal neurological deficits. The rest of his physical examination yielded no addition findings.
Laboratory investigations including biochemical and hematologic results obtained in the ER is listed below (Table 1). This revealed serum sodium 102mmol/L, serum osmolality 245mOsm/L, urine osmolality 44mOsm/L, urine sodium 7mmol/L, blood alcohol level 221mg/dL, and creatine kinase 7,810units/L. Random urine drug screen was positive for opiates. Initial electrocardiogram showed normal sinus rhythm (Figure 2). Chest x ray showed no acute cardiopulmonary process (Figure 1). About 45 minutes after presentation at the Emergency department, he experienced violent incessant episodes of generalized clonic-tonic seizure episode involving all limbs. This was concerning for status epilepticus and required sedation with phenobarbital and intubation for airway protection at the medical intensive care unit at our community hospital. Nephrology, critical care, and neurology consultation was subsequently placed.
Patient was given hypertonic saline with close monitoring of his serum sodium and electrolytes. The rise in serum sodium was 0.5-1mmol/L/h, serum sodium gradually improved to 120 over 2 days. The patient’s chest x-ray demonstrated possible right middle lobe pneumonia and he was started on broad spectrum antibiotics of ceftriaxone and azithromycin intravenously. The patient continued to be on mechanical ventilation and multiple attempts at extubating failed.
Over the next 24 to 48 hours, a change was noted on telemetry monitoring concerning for ST elevation and a 12-lead electrocardiogram showed early repolarization abnormalities in the left lateral leads (Figure 3). Follow up cardiac enzymes done showed troponin of 4.30 mg/mL, creatine kinase- MB 50U/L, creatine kinase 1293U/L.” The ST elevations did not qualify for classification as STEMI, however, he required urgent treatment for NSTE-ACS. The patient was, subsequently transferred to a neighboring hospital with percutaneous coronary intervention and cardiac catheterization capability.
He stayed on mechanical ventilation several days. Echocardiogram done prior to the left heart catherization showed left ventricular ejection fraction of 30% with severe mid-distal and apical hypokinesis and ballooning, relaxation abnormality of left ventricular hypertrophy with mild concentric left ventricular hypertrophy were also appreciated (Movie 1). The patient received aspirin, metoprolol and lisinopril orally with heparin intravenously as medical therapy.
The Left Heart Catheterization (LHC) done, showed no evidence of obstructive CAD (Figure 4). There was no evidence of coronary vasospasm. LV angiogram showed apical ballooning and hypokinesis of anteroseptal Left ventricle concerning for Takotsubo cardiomyopathy (Figure 5). The patient was monitored closely after the LHC. Troponin peaked at 33.0mg/mL and subsequently trended down 0.04mg/mL, 3 days after the LHC.
He remained on hypertonic saline with increases of his serum sodium to 123mmol/L. The hypertonic saline was stopped when his serum sodium increased to 129mmol/L. The sodium remained stable at 128 – 130mmol/L. He was successfully extubated, after 4 days of mechanical ventilation. His mental status slowly improved and began to respond to commands. Patient made steady improvement in his clinical condition, antibiotics was discontinued and was discharge after 6 days of hospital stay.
An Echocardiogram done a month post admission during a follow up clinic visit to our hospital showed left ventricular ejection fraction of 55% with resolution of apical hypokinesis and ballooning (Movie 2).