2019 Research Forum

Presenter: Sara Jaka MD R1 Principal Investigator & Faculty Sponsor: Tiffany Win MD An Unusual Case of Paraquat-Induced Rhabdomyolysis and Hepatic Injury Presenting with Takotsubo Cardiomyopathy

Sara Jaka MD R1, Jessica McFarland MS IV, Tasneem Khan MS III, Emily Gunz MS IV, Leila Moosavi MD R3, Carlos D’Assumpcao MD R1, Tana Parker MD, Fowrooz Joolhar MD, Arash Heidari MD, Tiffany Win MD

INTRODUCTION Takotsubo cardiomyopathy (TM) is a syndrome of reversible left ventricular (LV) systolic dysfunction commonly typified by LV apical ballooning andmid and apical segment hypokinesis without obstructive coronary artery disease. Its clinical presentation can be confused with acute coronary syndrome. Its diagnosis requires electrocardiogram, cardiac enzymes, transthoracic echocardiography, and coronary angiogram. PURPOSE This case presentation shows how prompt recognition of TM in this patient led to targeted management with guideline directed medical therapy which generated a very favorable outcome for her. IRB review and approval were obtained for this case report prior to analysis of her medical chart for assembly of the report. DISCUSSION A 45-year old Hispanic female with diabetes, hypertension, and dyslipidemia presented to the hospital with a chief complaint of progressive bilateral upper and lower extremity weakness over one month. She was found to have elevated troponins of 2.57 ng/ml and worked up for NSTEMI. Coronary angiogram showed no obstructive disease and transthoracic echo (TTE) showed a left ventricular ejection fraction (LVEF) of 20-25% with akinetic mid and distal segments and apical ballooning highly suggestive for TM. This patient was started on guideline-directed medical therapy for non-ischemic cardiomyopathy. Critical lab values on presentation were a CK of 14848 U/L, LDH of 1414 U/L, ALT of 748 U/L and AST 651 U/L. An extensive workup for infectious and rheumatologic causes of myopathy returned within normal limits. EMG studies were consistent with active myopathy. Further history from the patient elucidated that her muscle weakness began around the time she started working in a new grape field where paraquat had been sprayed one month prior. This was eventually confirmed by a local spraying company. This patient also reports having drank water from a tub filled with hose water while there. TTE repeated 6 days after admission showed a complete recovery of LVEF of 50-55% and no regional wall motion abnormalities coinciding with the patient regaining upper and lower extremity muscle strength and resolving CK and transaminitis. This patient was discharged and followed in cardiology clinic one week later where she demonstrated complete resolution of muscle weakness. CONCLUSION Paraquat, a non-selective contact herbicide, can lead to severe systemic toxicity. This case illustrates that reversible cardiomyopathy can develop in the setting of paraquat-induced rhabdomyolysis and hepatic injury. Obtaining a detailed history including occupational history and toxic exposure plays a critical role to identifying an accurate diagnosis and a reversible cause of the fatal disease. This patient was optimized with medical therapy at the time of diagnosis and had rapid recovery of LV function within 7 days along with complete resolution of her muscle weakness. Recognition of this rare presentation is crucial since disease progression may lead to severe multi-organ failure and early discontinuation of paraquat exposure can lead to an excellent outcome.

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