Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 46
Stress-induced (takotsubo) cardiomyopathy following thoracic
epidural steroid injection for postherpetic neuralgia
Nicholas P. McKernan, MD, Bryan J. Rondeau, MD, and Russell K. McAllister, MD
We present what may be the first documented case of takotsubo cardiomyopathy following a thoracic epidural steroid injection. The 77-year-old
patient had many risk factors predisposing her to takotsubo cardiomyopathy, including gender, postmenopausal status, and numerous recent
stressful events in her life. Although she presented to the emergency
department with symptoms of an acute myocardial infarction, her findings
on electrocardiography, echocardiography, coronary angiography, and
cardiac enzymes supported the diagnosis of takotsubo cardiomyopathy.
While takotsubo cardiomyopathy is rare, it is important for the clinician to
distinguish it from an acute myocardial infarction, as the two conditions
present similarly but may have distinctly different clinical outcomes.
akotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, is a transient systolic dysfunction
of the left ventricle typically triggered by an acute illness
or intense emotional or physical stress (1). Postherpetic
neuralgia (PHN) is pain persisting in a herpes zoster–affected
area >6 months after healing of the zoster eruptions (2). We
present a patient with significant psychosocial stressors who
underwent a thoracic epidural steroid injection for treatment
of PHN and then developed TC.
T
CASE REPORT
A 77-year-old woman with PHN returned to our anesthesia
pain clinic for a repeat thoracic epidural steroid injection. Prior
treatment with epidural steroid injections, propoxyphene, and
gabapentin had adequately managed her pain. Previously, she
had herpes zoster, multiple myeloma, stage III chronic kidney
disease, anemia, hypertension, hypothyroidism, a deep venous
thrombosis, and degenerative disk disease. A brother had recently died, and her husband had recently been admitted to a
nursing home for his declining health.
After reexamination, a T4-5 epidural steroid injection under
fluoroscopic guidance was planned. No sedation was administered.
The patient was positioned prone on the fluoroscopy table, and the
overlying tissue was anesthetized with 1% lidocaine. A 17-gauge
Tuohy needle was inserted via a left paramedian approach under
fluoroscopic guidance, and the loss of resistance technique was used
to identify the epidural space on the first pass. After negative aspiration of blood or cerebrospinal fluid, a solution containing 80 mg of
triamcinolone and 4 mL of 0.125% bupivacaine was injected.
120
The patient remained stable throughout the procedure. At
discharge, she had no new neurological deficits or complaints.
She attended an unrelated appointment and then returned
home to take a nap. Soon after, she developed a headache and
progressively worsening chest pain. She was taken to the emergency department (ED), where she reported substernal chest
pain radiating into her left neck, dyspnea, nausea, and an episode of vomiting.
While in the ED, she received nitroglycerin, fentanyl, heparin, and aspirin. An electrocardiogram showed mild ST-segment
elevation with Q waves in the precordial leads and widening
of the QRS complex. Her troponin was 0.09 ng/mL on arrival to the ED and 1.84 ng/mL 4 hours later. A transthoracic
echocardiogram demonstrated depression of the apex of the
left ventricle with apical ballooning, preserved wall motion of
the basal segments, and an estimated ejection fraction of 30%.
Cardiac catheterization revealed only mild narrowing of the left
main coronary artery. Her troponin level peaked at 2.7 ng/mL.
A repeat echocardiogram on hospital day 3 showed improvement of her ventricular function, and her troponin level had
dropped to 1.0 ng/mL. She was discharged home on hospital
day 4. A repeat echocardiogram 20 days later showed no regional wall motion abnormalities and an estimated ejection
fraction of 55%.
DISCUSSION
While there is an abundance of literature regarding the treatment of PHN, we know of no previously reported cases of TC
following an epidural steroid injection. TC derives its name
from the echocardiographic appearance of the heart, which
resembles a “takotsubo,” the Japanese word for an octopus trap.
The typical appearance is characterized by mid and apical segmental depression of the left ventricle with compensatory basal
wall hyperkinesis that results in ballooning of the left ventricular
apex during systole (3).
The condition is typically triggered by severe stress (e.g.,
severe illness, a catastrophic event, death in the family) and
From Baylor Scott & White Health and Texas A&M Health Science Center College
of Medicine, Temple, Texas.
Corresponding author: Russell K. McAllister, MD, Department of Anesthesiology,
Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508 (e-mail:
[email protected]).
Proc (Bayl Univ Med Cent) 2014;27(2):120–121