A case of takotsubo cardiomyopathy in a patient with anaphylaxis treated with epinephrine

Takotsubo cardiomyopathy (TTC) is a recently identified transient cardiomyopathy that is usually associated with emotional or physical stress. Catecholamine surge appears to be central to the mechanism of TTC. TTC in the setting of anaphylaxis is rare. We present a case of a 58-year-old female was referred from an outside hospital after being diagnosed with anaphylaxis. She received 0.3 mg epinephrine intramuscularly and 1 mg intravenously. Upon admission to our hospital, she was complaining of chest pain. EKG done in the outside hospital showed ST elevations in the anterior leads but the EKG done at our hospital was normal. She had to be intubated in view of impending airway obstruction. She was subsequently started on epinephrine infusion in the intensive care unit for hypotension. She was found to have elevated troponins that trended up. An echocardiogram performed on day 3 revealed a left ventricular ejection fraction of 25% and apical hypokinesis suggestive of TTC. Cardiac catheterization was initially deferred in view of a history of dye allergy. A nuclear stress test was done instead that revealed reversible ischemia in anteroseptal regions. Cardiac catheterization was performed eventually with pre-medication that showed a near-normal coronary circulation. A repeat echocardiogram performed 6 weeks after discharge showed normal systolic function.