Typical and reverse Takotsubo syndromes as initial manifestations of consecutive Addisonian crises in a 38-year-old patient: the heart has its reasons!

Abstract

We report an interesting case of a 38-year-old woman presenting with reverse Takotsubo syndrome (TTS) secondary to an Addisonian crisis, her second such episode. A few years prior, she had presented with typical TTS in the setting of Addisonian crisis; diagnostic work-up revealing Auto-Immune Polyglandular Syndrome Type II (APS II). We believe this to be the first case report of typical and variant phenotypes of TTS in a patient with APS II. The pathogenic link between these two conditions is explored. In patients presenting with Addisonian crises and refractory shock, the possibility of concurrent TTS should be considered. TTS muddies the diagnostic waters and poses therapeutic challenges as outlined.

Keywords: adrenal disorders; cardiovascular medicine; clinical diagnostic tests; heart failure; interventional cardiology.

Figure 1

ECG on admission to the coronary care unit. HR, Heart rate 120 beats per minute, RR, RR interval 500 ms, PR, PR interval 148 ms, QRSd, ventricular depolarization 90ms, QT, QT interval 375 ms, QTc, corrected QT interval 530 ms.

Figure 2

Initial left ventricular angiogram 4 years prior to this presentation, demonstrating typical Takotsubo syndrome.

Figure 3

Cardiac MRI demonstrating a mildly dilated left ventricle with global hypokinesis and moderate systolic dysfunction.