REVERSE TAKUTSUBO CARDIOMYOPATHY ASSOCIATED WITH PHLEGMASIA CERULEA DOLENS F Echefu MD, D Hammett MD, C Forrester MD, A Ausef MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA INTRODUCTION: Phlegmasia cerulea dolens is a rare but potentially fatal complication of acute massive deep venous thrombosis characterized by severe pain and swelling of the extremities with cyanosis. It is rarely associated with reverse takotsubo syndrome (TTS). Takotsubo syndrome is a sudden onset, but reversible acute heart failure syndrome commonly associated with intense emotional or physical stress with higher incidence in postmenopausal women. CASE: A 56-year-old male presented with lower extremity pain, swelling and bluish discoloration of left leg that began the previous week. At presentation, he was tachycardic and hypotensive with no palpable left distal pulses. Lower extremity venous duplex showed completely occluded unilateral left proximal superficial and deep venous thrombi. He was admitted to the hospital and underwent urgent ultrasonic catheter directed thrombolysis and heparin drip under close supervision in the intensive care unit. On day 3, he complained of chest pain and atrial fibrillation with rapid ventricular response was noted on cardiac monitor. EKG revealed anterior ST-elevation myocardial infarction, absent on prior EKG. Transthoracic echocardiogram revealed left ventricular ejection fraction of 20% with apical hypokinesis. He underwent cardiac catheterization (CC) revealing basal hypokinesis with hyperdynamic left ventricular apex, left ventricular ejection fraction of 35%, and no obstructive coronary artery lesion. A diagnosis of reverse Takotsubo syndrome was made. DISCUSSION: We report the reverse variant of TTS, a rarer form, in which there is hyperdynamic apex and hypokinesis of the basal segments of the left ventricle observed on echocardiography and left cardiac catheterization. It has similar presentation as acute coronary syndrome, confusing and delaying its diagnosis. The hallmark differences are non-obstructive coronary vasculature and reversibility seen in TTS. Several etiologies have been reported in the pathogenesis of reverse takotsubo cardiomyopathy such as catecholamine excess, coronary artery spasm and microvascular dysfunction. Venous thromboembolism specifically pulmonary embolism is a rare but important etiology. To date no known case of phlegmasia cerulean dolens has been associated with TTS in literature.
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