BRIEF OBSERVATION Apical Ballooning Resulting from Limbic Encephalitis Jill Gelow, MD, MPH, a Michael Kruer, MD, b Vijayshree Yadav, MD, c,d Sanjiv Kaul, MD a a Division of Cardiovascular Medicine, b Department of Medicine, Divisions of Pediatric Neurology and Developmental Pediatrics, c Department of Pediatrics, and d Division of Neuroimmunology, Department of Neurology, Oregon Health and Science University, Portland. ABSTRACT BACKGROUND: Neurogenic stunned myocardium is an increasingly recognized cause of left ventricular apical ballooning, or takotsubo cardiomyopathy. We report the first case of neurogenic stunned myocar- dium as a result of limbic encephalitis. METHODS: This 73-year-old woman with anterograde and retrograde amnesia was investigated using electrocardiography, magnetic resonance imaging, and left ventricular angiography. RESULTS: Electrocardiography showed deep T-wave inversions in multiple leads, magnetic resonance imaging demonstrated increased signal on fluid-attenuated inversion recovery images symmetrically within the medial temporal lobes consistent with limbic encephalitis. Left ventricular angiography showed apical ballooning. CONCLUSIONS: Because the insula has extensive interconnections with limbic structures, limbic enceph- alitis could lead to alterations in the sympathetic regulation of the insular cortex resulting in neurogenic stunned myocardium. © 2009 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2009) 122, 583-586 KEYWORDS: Apical ballooning; Limbic encephalitis; Stunned myocardium Neurogenic stunned myocardium is an increasingly recog- nized cause of takotsubo cardiomyopathy, most often attrib- uted to subarachnoid hemorrhage or stroke. 1-7 We report the first case of neurogenic stunned myocardium associated with limbic encephalitis. CASE REPORT A 73-year-old woman was admitted with anterograde and retrograde memory loss. A noncontrast head computed to- mography scan was unremarkable, and an electroencepha- logram showed no evidence of seizure activity. Cerebral spinal fluid analysis revealed glucose of 90 and protein of 55 mg/dL. There were 27 erythrocytes and 36 leukocytes per cubic mm, with 88% lymphocytes and 12% monocytes. Herpes simplex virus polymerase chain reaction and bacte- rial culture were negative. Cytology was negative for malignancy. Magnetic resonance imaging demonstrated increased signal on fluid-attenuated inversion recovery images symmetrically within the medial temporal lobes without enhancement or mass effect. There was an area of in- creased signal in the anterior cerebellar vermis (Figure 1). These findings were consistent with limbic encephalitis. An extensive malignancy work-up was notable only for multiple left axillary lymph nodes, the largest measuring 12 by 15 mm, demonstrated on whole body computed tomog- raphy scan, and biopsy demonstrated reactive hyperplasia with no evidence of lymphoma or metastatic disease. Se- rologic testing for paraneoplastic antibodies was nega- tive. An electrocardiogram showed normal sinus rhythm Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data. Drs. Gelow and Kaul were consultant cardiologists to the case. Drs. Kruer and Yadav took care of the patient. All assisted in writing the article and devel- oping the figures. Requests for reprints should be addressed to Sanjiv Kaul, MD, Division of Cardiovascular Medicine, Oregon Health and Science Uni- versity, UHN62, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239-3098. E-mail address: kauls@ohsu.edu 0002-9343/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2008.12.016