Postpartum woman with pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy: a case report

Abstract

Introduction: Pneumomediastinum is known to occur during labor. Patients typically present with chest pain and symptoms may be suspicious, for example of pulmonary embolism or aortic dissection. The condition itself, however, is rather harmless and self-limiting.Takotsubo cardiomyopathy is associated with psychologically or physiologically stressful events and its symptoms mimic myocardial infarction. Yet, symptoms often improve quickly as the initially impaired cardiac function is usually restored within days or weeks.Although the initial presentation of the patient in this case report was dramatic, the clinical course was positive and the patient could be quickly dismissed in a good general condition. To the best of our knowledge, no presentation of a combined occurrence of postpartum pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy exists.

Case presentation: We present the case of a 30-year-old Caucasian woman with sudden onset of thoracic back and chest pain approximately 24 hours after an otherwise unremarkable vaginal delivery. A contrast-enhanced chest computed tomography showed cervical and mediastinal emphysema without proof for pulmonary embolism or aortic dissection. She received a symptomatic analgesic treatment and was dismissed to the obstetrics department for monitoring.Within hours, slightly increased levels of troponin I were observed without corresponding electrocardiography changes. Immediate cardiac catheterization and a cardiovascular magnetic resonance imaging (performed within 24 hours) revealed basal to midventricular hypokinesia, but were otherwise unremarkable. A low-dose treatment for congestive heart failure was initiated, under which symptoms subsided within days. She was dismissed after 12 days in a good general condition.

Conclusions: Although the clinical presentation of the combination of the diseases initially was dramatic, the prognosis is positive. In the context of the preceding delivery, knowledge about the postpartum pneumomediastinum lets the radiologist of the emergency department quickly make this diagnosis. The takotsubo cardiomyopathy, however, needs broader diagnostics to not miss intervention-requiring causes.

Figure 1

X-ray and chest computed tomography at initial presentation. a shows the chest X-ray of the patient that reveals a thin stripe of increased transparency along the left side of her trachea. b to d show slices of the chest computed tomography that reveal cervical and mediastinal emphysema.

Figure 2

Cardiac catheterization. Hemodynamically not relevant kinking of the left anterior descending artery. Coronary arteries are otherwise unremarkable. Left ventricle angiography suggests basal to midventricular ballooning. Abbreviations: LCA, left coronary artery; RCA, right coronary artery; LV, left ventricle angiography.

Figure 3

Native cardiac magnetic resonance imaging cine sequences. The row above shows the end diastolic, the row below the end systolic state of the cardiac cycle. Column a shows a patient with normal left ventricular function and a symmetric contractility of the myocardium throughout the left ventricle, b shows a patient with takotsubo cardiomyopathy with normal contractility of the basal myocardium and impaired apical contractility with ballooning, c is the patient of this case report with reverse (inverted) takotsubo cardiomyopathy with normal contractility of the apical myocardium and impaired contractility of the basal parts.