First case of Takotsubo Syndrome associated with COVID-19
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This report is the first case of Takotsubo cardiomyopathy associated with COVID-1. It discusses a rare presentation in the current pandemic. COVID-19 can be associated with cardiac complications, even after the onset of pneumonia and so strict monitoring of these patients is essential.

An 87-year-old woman was admitted to the clinic on 24 March 2020, with fever, fatigue and shortness of breath. She had a history of breast cancer, but no hypertension, diabetes or obstructive pulmonary disease. She reported no travel to China or possible contact with infected individuals. She had experienced chills and a dry cough 2 weeks previously but had not sought medical advice. A chest x-ray showed multiple patchy shadows in both lungs and parenchymal thickening with bilateral basal alveolar interstitial infiltrates compatible with COVID-19. A nasopharynx swab sample was taken. Using reverse real-time PCR assay, the laboratory confirmed on 25 March that the patient was positive for SARS-CoV-2.

She was immediately admitted to the isolation ward and received supplemental oxygen through a face mask, achieving an oxygen saturation of 91%. She was also treated with azithromycin and ceftriaxone. Given the serious shortness of breath and hypoxaemia, methylprednisolone was administered to reduce lung inflammation.

Laboratory test results showed 1.17% lymphocytes, 95.8% neutrophils and C-reactive protein of 205.6. Oxygen pressure was 47 mmHg with a PO2/FO2 of 226. On the second day of hospitalisation, the patient had an episode of tachycardia with an increase in cardiac laboratory markers: troponin I was 5318 ng/l and CK-MB was 55 µg/l. The electrocardiogram showed negative T waves and repolarization phase alterations.

An echocardiogram was therefore performed and showed alterations in the left ventricle: apical akinetic expansion (apical ballooning) and hypokinesia of the mid-ventricular segments with slightly reduced systolic function (ejection fraction slightly reduced to 48%). The clinical, laboratory and radiological picture was diagnostic for Takotsubo syndrome. Due to the age of the patient, coronary angiography was not possible but treatment with bisoprolol and fondaparinux was started. The patient was discharged in good clinical conditions.

Several mechanisms have been hypothesized as possible causes of this syndrome. In this case, greater myocardial reactivity to sympathetic stimulation (caused indirectly by pneumonia) in the apical region combined with abnormal vascular reactivity (induced directly by the virus) could have determined the onset of the left ventricular dysfunction seen in Takotsubo syndrome.

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