Letter to the Editor Tako-Tsubo cardiomyopathy following an allergic asthma attack after cephalosporin administration Francesco Santoro a , Michele Correale a , Riccardo Ieva a , Maria Filomena Caiaffa b , Ilaria Pappalardo b , Matteo Di Biase a , Natale Daniele Brunetti a, ⁎ a University of Foggia, Cardiology Department, Foggia, Italy b University of Foggia, Allergology Department, Foggia, Italy article info Article history: Received 8 November 2011 Accepted 26 November 2011 Available online xxxx Keywords: Tako-Tsubo cardiomyopathy Allergy IgE Right ventricular apical ballooning Left ventricular apical ballooning Cephalosporin Tako-Tsubo (TT) syndrome is characterized by acute onset of chest symptoms, ECG changes with elevated cardiac markers mim- icking acute myocardial infarction, left ventricular (LV) wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries [1]. Those affected are typically older women presenting after a stressful trigger, either emotional or physical. A 70-year-old woman with history of hypertension, diabetes, asthma and allergy, was admitted with chest pain and dyspnea, which suddenly appeared after a single 1 g dose of ceftriaxone i.m. as- sumed because of cough and fever. On physical examination, blood pressure was 120/70 mm Hg, heart rate 110 bpm, respiratory rate 22 breaths/min, and diffuse bilateral wheezes were found. ECG showed sinus rhythm and mild ST-elevation in anterior leads (Fig. 1a); troponin-I levels were increased (1.09 m ng/ml (n.v. b 0.03)). Trans-thoracic echocardiogram showed LV systolic dysfunc- tion (ejection fraction [EF] 25%) with both apical dyskinesis and basal hyperkinesis (Fig. 1c), and right ventricular (RV) apical dyskin- esis (Fig. 1d). Mild mitral regurgitation and tricuspid regurgitation were also detectable at color Doppler analysis. Total IgE circulating levels were increased (1270 I.U./ml (n.v. b 240 I.U./ml). Coronary an- giography showed normal coronary arteries and confirmed LV apical ballooning (Fig. 1e–f). Medical treatment with furosemide, levosimendan, ramipril, and bisoprolol was therefore started. The patient gradually recovered, and was discharged a week later, when all ECG anomalies, after transient onset of negative T-waves (Fig. 1b) disap- peared. Pre-discharge echocardiography showed both improved LV (EF 55%) and RV systolic functions. We report a case of transient apical ballooning triggered by admin- istration of antibiotics (cephalosporin). We therefore hypothesize that allergic activation induced by antibiotic and featured by increased IgE levels may be related to TT phenomenon, as previously reported [2]. RV apical ballooning, as found in this patient, was reported in 25% of cases with TT syndrome [3]. The exact mechanism leading to transient apical systolic dysfunc- tion is still not well elucidated. Increased catecholamine levels were though as responsible [4] , but also coronary spasm has been reported in subjects showing TT phenomenon [5]. Several prior reports linked TT syndrome to bronchial asthma [6] anaphylactic reaction [7,8] and even cephalosporin administration [9], although in all these cases apical systolic dysfunction usually fol- lowed administration of i.v. epinephrine. We therefore postulate in this patient a catecholamine independent pathway leading to TT phe- nomenon. Direct histamine effect consequent to allergic activation may be presumed as responsible for transient apical dysfunction. Two cases of profound reversible myocardial dysfunction occurring in the setting of anaphylaxis, with histamine discussed as a potential myo- cardial depressor, were previously reported [10]. Raper et al. noted that stimulation of histamine receptors in both animal and human hearts ex- perimentally leads to myocardial depression, providing a possible explaining mechanism for our findings. References [1] Donohue D, Movahed MR. Clinical characteristics, demographics and prognosis of transient left ventricular apical ballooning syndrome. Heart Fail Rev 2005;10: 311–6. [2] Dewachter P, Tanase C, Levesque E, et al. Apical ballooning syndrome following perioperative anaphylaxis is likely related to high doses of epinephrine. J Anesth 2011;25:282–5. [3] Haghi D, Athanasiadis A, Papavassiliu T, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27:2433–9. [4] Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. [5] Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to si- multaneous multivessel coronary spasm: a review of 5 cases. J Cardiol 1991;21: 203–14. [6] Levine GN, Powell C, Bernard SA, Sherman D, Faling LJ, Davidoff R. Acute, reversible left ventricular dysfunction in status asthmaticus. Chest 1995;107:1469–73. International Journal of Cardiology xxx (2011) xxx–xxx ⁎ Corresponding author at: Viale Pinto 1, 71100 Foggia, Italy. Tel.: + 39 3389112358; fax: + 39 0881745424. E-mail address: nd.brunetti@unifg.it (N.D. Brunetti). IJCA-14264; No of Pages 2 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.11.106 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: Santoro F, et al, Tako-Tsubo cardiomyopathy following an allergic asthma attack after cephalosporin administration, Int J Cardiol (2011), doi:10.1016/j.ijcard.2011.11.106