Initial Presentation
A 72-year-old woman presented to the emergency department with nausea and vomiting after a two-week course of doxycycline and clarithromycin for a lower respiratory tract infection. Diagnosed with sepsis, she received intravenous fluids and antibiotics. Her condition stabilized and she was transferred to the acute medical unit. Her medical history was notable for severe mitral stenosis with a permanent pacemaker for complete heart block, and signs of heart failure were evident on examination—including generalized edema and a pan-systolic murmur.
Cardiac Imaging
An echocardiogram revealed extensive akinesis of the mid and apical segments of the left ventricle (LV), with preserved contractility at the basal segments—suggesting a pattern of stress cardiomyopathy (Takotsubo cardiomyopathy, TCM). The ejection fraction was severely reduced to 35%. Diastolic assessment was limited due to pacing and valvular disease, but the regional wall motion abnormalities (WMAs) raised clinical suspicion.
Angiography Rules Out Obstructive Coronary Disease
Coronary angiography demonstrated only mild to moderate coronary artery disease, not severe enough to explain the degree of LV dysfunction. Mild calcification and diffuse disease were noted in the coronary vessels, but no critical stenosis. This further supported a diagnosis of TCM rather than an ischemic cardiomyopathy.
Autoimmunity History
The patient had an extensive autoimmune background, including type 1 diabetes mellitus, sarcoidosis, primary biliary cholangitis, asthma, Sjogren’s syndrome, and cryoglobulinaemia. A childhood history of rheumatic fever had also led to progressive mitral valve disease. While no acute emotional stressor was identified, the burden of multiple chronic diseases and functional dependence may have served as a cumulative stress trigger for TCM.
Recovery Without Intervention
Under conservative management and close observation, the patient gradually improved without specific cardiac interventions. Ten weeks later, a follow-up echocardiogram showed complete recovery of LV function, with normalization of ejection fraction to 60–65% and resolution of regional wall motion abnormalities—consistent with the reversible nature of stress cardiomyopathy.
