‘Might Imperial Caesar, dead and turned to clay, stop a hole to keep the wind away?’

‘Might Imperial Caesar, dead and turned to clay, stop a hole to keep the wind away?’ Cardiovascular flashlight 2117 doi:10.1093/eurheartj/ehy145 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 15 March 2018 .................................................................................................................................................... ‘Might Imperial Caesar, dead and turned to clay, stop a hole to keep the wind away?’ 1 1 2 1 1 Domenico D’Amario *, Antonino Buffon , Sonia D’Arrigo , Francesca Lassandro Pepe , and Filippo Crea * 1 2 Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy; and Institute of Anaesthesiology and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy * Corresponding author. Tel: 0039-063015; ext 4187, Fax: 0039-063055535, Email: domenico.damario@gmail.com A 73-year-old woman, with advanced breast Admission in the ICU cancer, who consistently refused surgical A resection, was admitted in emergency room for an acute respiratory failure, associated with generalized muscle rigidity, trismus, hyperpyr- exia, sweating which needed neuromuscular blocking agent and an early tracheostomy to avoid tube biting and obstruction. No previous 24h later – Index procedure cardiac history reported. Over the last weeks, for the occurrence of sec- ondary skin ulceration, the patient was advised to apply clay mud over the breast. Subsequently, she developed an extensive local necrosis (Panel A). Microbiological results from necrosectomy revealed Clostridium tetani and Clostridium sporo- genes. Human tetanus globulin, intravenous ceph- alosporin, and high dosage of benzodiazepines D were administered. Electrocardiogram on admission showed a pro- longed QT interval without any evidence of ST segment depression (InterTAK Score: 56) (Panel B) and hsTroponin was 1.46, peaking 3.95 ng/mL. The clinical course rapidly deteriorated with vegetative crisis and haemodynamic instability associated with atrial fibrillation and ST segment aLAP= 21 mmHg elevation (Panel C). Coronary angiography was performed: no evi- dence of obstructive epicardial coronary atheroscle- rosis was observed. Following the 2017 ST aLVEDP = 31 mmHg elevation myocardial infarction guidelines, left ven- tricular angiography was performed showing an api- cal type takotsubo syndrome (TTS), with high left ventricular end-diastolic pressure and left atrial pres- sure (Panel D; Supplementary material online, Videos S1–S3). Sadly, the patient died less than 48 h later. To the best of our knowledge, this is the first report documenting a TTS in a patient with a diagnosis of tetanus, in which catecholamine levels may increase due to the tetanus toxin. As recently demonstrated, TTS may be a life-threatening condition: early cardiac catheterization is fundamental to make a correct diagnosis. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/22/2117/4938782 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

‘Might Imperial Caesar, dead and turned to clay, stop a hole to keep the wind away?’

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Publisher
Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
ISSN
0195-668X
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1522-9645
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10.1093/eurheartj/ehy145
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Abstract

Cardiovascular flashlight 2117 doi:10.1093/eurheartj/ehy145 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 15 March 2018 .................................................................................................................................................... ‘Might Imperial Caesar, dead and turned to clay, stop a hole to keep the wind away?’ 1 1 2 1 1 Domenico D’Amario *, Antonino Buffon , Sonia D’Arrigo , Francesca Lassandro Pepe , and Filippo Crea * 1 2 Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy; and Institute of Anaesthesiology and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy * Corresponding author. Tel: 0039-063015; ext 4187, Fax: 0039-063055535, Email: domenico.damario@gmail.com A 73-year-old woman, with advanced breast Admission in the ICU cancer, who consistently refused surgical A resection, was admitted in emergency room for an acute respiratory failure, associated with generalized muscle rigidity, trismus, hyperpyr- exia, sweating which needed neuromuscular blocking agent and an early tracheostomy to avoid tube biting and obstruction. No previous 24h later – Index procedure cardiac history reported. Over the last weeks, for the occurrence of sec- ondary skin ulceration, the patient was advised to apply clay mud over the breast. Subsequently, she developed an extensive local necrosis (Panel A). Microbiological results from necrosectomy revealed Clostridium tetani and Clostridium sporo- genes. Human tetanus globulin, intravenous ceph- alosporin, and high dosage of benzodiazepines D were administered. Electrocardiogram on admission showed a pro- longed QT interval without any evidence of ST segment depression (InterTAK Score: 56) (Panel B) and hsTroponin was 1.46, peaking 3.95 ng/mL. The clinical course rapidly deteriorated with vegetative crisis and haemodynamic instability associated with atrial fibrillation and ST segment aLAP= 21 mmHg elevation (Panel C). Coronary angiography was performed: no evi- dence of obstructive epicardial coronary atheroscle- rosis was observed. Following the 2017 ST aLVEDP = 31 mmHg elevation myocardial infarction guidelines, left ven- tricular angiography was performed showing an api- cal type takotsubo syndrome (TTS), with high left ventricular end-diastolic pressure and left atrial pres- sure (Panel D; Supplementary material online, Videos S1–S3). Sadly, the patient died less than 48 h later. To the best of our knowledge, this is the first report documenting a TTS in a patient with a diagnosis of tetanus, in which catecholamine levels may increase due to the tetanus toxin. As recently demonstrated, TTS may be a life-threatening condition: early cardiac catheterization is fundamental to make a correct diagnosis. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/22/2117/4938782 by Ed 'DeepDyve' Gillespie user on 21 June 2018

Journal

European Heart JournalOxford University Press

Published: Mar 15, 2018

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