Acute cardiomyopathy in rheumatoid associated lung disease

A 67 year old lady with rheumatoid arthritis on prednisolone, methotrexate and hydroxychloroquine was admitted with chest pains, breathlessness and blood stained sputum. She had a history of obliterative bronchiolitis and bronchiectasis secondary to rheumatoid, previously treated with cyclophosphamide and Rituximab immunosuppression. An ECG at presentation showed T wave inversion in the anteroseptal leads. Subsequent Troponin I was positive. CT pulmonary angiography revealed no evidence of PE. Antiplatelet agents were commenced. Serial ECGs showed dynamic changes and the patient underwent urgent coronary angiography, which revealed entirely normal coronary arteries but an abnormal left ventriculography. There was marked LV apical hypokinesis and ballooning. Cardiac MRI supported the suspicion of Takutsubo9s cardiomyopathy. Discussion: Takutsubo9s cardiomyopathy is a cause of cardiac chest pain and troponin release, accounting for up to 2% of ST-elevation myocardial infarction (MI). To our knowledge Takutsubo9s is undescribed in patients with rheumatoid bronchiolitis obliterans and bronchiectasis. The similarity in presentation to MI and pulmonary embolism creates diagnostic confusion.Whether the lung inflammation associated with rheumatoid confers an additional risk for Takutsubo9s remains unknown. This diagnosis therefore warrants consideration as unnecessary anticoagulation and antiplatelet therapies may have dangerous sequelae.