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Takotsubo cardiomyopathy associated with Guillain–Barré syndrome: A differential diagnosis from dysautonomia not to be missed

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Abstract

A 60-year-old woman presented with a 1-week progressive limb weakness and an areflexic tetraparesis. Both neurophysiological and cerebrospinal fluid examinations were consistent with diagnosis of Guillain–Barré syndrome (GBS) and a treatment by intravenous immunoglobulin over a 5-day period was started. At the end of the treatment, the patient suffered from an acute coronary syndrome (ACS) without stenosis at coronary arteriography. Left ventriculography showed segmental wall motion abnormalities with apical akinesis contrasting with hyperkinesis in basal segments, with a depressed left ventricular ejection fraction at 45%. Cardiac magnetic resonance imaging excluded the diagnosis of myocarditis. A diagnosis of “transient left ventricular apical ballooning syndrome” or “Takotsubo” syndrome was then made and a treatment by angiotensin-converting enzyme inhibitor and β-blocker was introduced. Left ventricular dysfunction and electrocardiogram normalized within two weeks and the patient remained free from cardiovascular events at one year of follow-up. This cardiomyopathy is a recently known and now commonly diagnosed reversible systolic dysfunction mimicking ACS and is secondary to physical or emotional stress affecting mainly post-menopausal women. Electrocardiographic and echocardiographic abnormalities are often regressive in days or weeks, and rarely responsible for complications. This observation supports clinical evidence that electrocardiographic changes in GBS can be linked to Takotsubo syndrome, by means of the stressful trigger of GBS occurrence. This reversible cardiomyopathy needs adequate management and specific therapeutic strategies. Therefore, trans-thoracic echocardiography should be systematically performed when repolarisation abnormalities are present in this disease to rule out a Takotsubo syndrome, even in asymptomatic patients.

Introduction

The Guillain–Barré syndrome (GBS) is an autoimmune disease affecting the peripheral nervous system, which may present with autonomic dysfunction, including electrocardiographic changes. In this report, we describe the case of a patient suffering from a GBS who had asymptomatic electrocardiographic abnormalities not related to dysautonomia but to a transient left ventricular apical ballooning cardiomyopathy, also called “Takotsubo syndrome”, who needs adequate management and specific therapeutic strategies. This diagnosis should not be missed. Therefore, a trans-thoracic echocardiography should be performed when repolarisation abnormalities are present in GBS, even in asymptomatic patients, as this easy paraclinic tool can diagnose an unexpected cardiomyopathy.

Section snippets

Case presentation

A 60-year-old woman presented with a 1-week progressive limb weakness and an areflexic tetraparesis. Her only cardiovascular risk factor was hypertension.

Nerve conduction study disclosed reduced motor conduction velocity in all limbs, particularly in the lower limbs. The sensory conduction was normal in the lower limbs. Needle electromyogram showed a slight reduction in the pattern of recruitment during effort in all muscles examined, and fibrillation potentials were absent. Cerebrospinal fluid

Discussion

The GBS is an autoimmune disease affecting the peripheral nervous system, which may present with autonomic dysfunction (hypotension, hypertension, sinus tachycardia, and electrocardiographic changes) [1], [2], [3]. There have been few case reports associating GBS and electrocardiographic abnormalities or left ventricular dysfunction [2], [4], [5]. Usually explained by temporary alterations in cardiac innervations or catecholamine cardiotoxicity, ECG abnormalities are often regressive. We

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