Case Presentation: A 64-year-old Caucasian female patient with no significant medical history came to medical attention in December 2016 with an episode of generalized tonic clonic seizure. On admission, review of systems, vital signs and physical examination were unremarkable. The following laboratory tests were normal or negative: complete metabolic panel, complete blood count, urinalysis, chest X-ray, electrocardiogram and computed tomography (CT) scan of the head without contrast. Within 24 hours of admission, she developed hypotension with the lowest blood pressure reading of 71/48 mmHg associated with tachycardia of 120 beats per minute. Repeat review of systems and physical examination were unremarkable. Repeat laboratory testing was significant for a new troponin elevation of 3.13 ng/ml. EKG revealed new diffuse symmetric T wave inversions. Echocardiogram showed systolic dysfunction of apical and mid-ventricular segments of the left ventricle associated with apical ballooning suggestive of Takotsubo cardiomyopathy which was confirmed by absence of intracoronary thrombus on an unremarkable coronary angiogram. Overall, the clinical presentation was compatible with Takotsubo cardiomyopathy caused by isolated generalized tonic clonic seizure. The patient was monitored in coronary care unit with supportive therapy and showed good clinical response with complete reversal of echocardiographic abnormalities at six month followup visit.
Discussion: Takotsubo cardiomyopathy, also called stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome is a transient acute catecholamine toxicity of the myocardium, and if diagnosed early and managed is associated with low mobidity and mortality. There are multiple neurological triggers of TC but the association between the first seizure episode and TC is underreported. In a small case series of 15 patients, about 33.3% of TC was associated with generalized tonic clonic seizures. It is also reported that due to excess cathecholamine release; cardiac arrhythmias and conduction abnormalities are more common in seizure related TC. We are reporting a rare case of an isolated generalized tonic clonic seizure resulting in TC.
Conclusions: TC should be included in the differential diagnoses of acute cardiac events in patients with seizures; and routine electrocardiogram should be considered after any seizure episode irrespective of cardiac symptoms. There is a well reported association between epilepsy and TC likely explaining Sudden Unexpected Death in Epilepsy (SUDEP), but the association between the first episode of seizure and TC is underreported and further needs to be explored.