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).