CONGRESS ABSTRACT

A 71-years-old woman presented to the emergency department of our institution. In the last three weeks she had fever with acme at 40 °C associated with general malaise and intense asthenia. The patient also complained of two syncopal episodes which prompted her to go to the hospital. The physical examination was normal.Inflammation indeces were elevated and blood cultures turned positive for E.coli. During the stay she complained of intense asthenia and abdominal pain. An urgent abdominal ultrasound showed three hepatic abscesses. An urgent total body CT scan (figure 1) confirmed the presence of abscess. A diagnosis of sepsis due to hepatic abscesses was done, Meropenem was started and a ultrasound-guided drainage of the hepatic abscesses was done. In order to study the syncope a transthoracic echocardiogram (TTE) was performed revealing a left ventricle normal in size but with a mild systolic dysfunction due to akinesia of the apex, EF 46% (figure 2). Of note, on admission and during the stay the patient did not complaint chest pain. A new ECG showed a normofrequent sinus rhythm and negative T waves in all the leads (figure 3). A differential diagnosis between acute coronary syndrome, acute myocarditis and secondary Takotsubo syndrome had to be done. Serial troponin measurements and a coronary CT were performed. They were normal. After a few days cardiac MRI showed an early recovery of the LV, with only mild and diffuse hypokinesia, EF 49%, and excluded focal structural changes and pathologic delayed-enhancement areas related to myocardial fibrosis/necrosis (figure 4). A diagnosis of Tako-tsubo syndrome (TS) secondary to the sepsis was made. The patient was treated with Bisoprolol, Valsartan, Acetilsalicil acidg, Atorvastatin. Thereafter she experienced a progressive clinical improvement with remission of fever and was finally discharged apiretic, eupnoic and hemodynamically stable. Two weeks later she was in good clinical status and a TTE showed a complete recovery of the LV function and a normal ECG. The diagnosis of TS should be considered in case of stressful physical triggers. Non invasive imaging is the key for every single step of the diagnosis : TTE is essential for the first working diagnosis, cardiac CT for the exclusion of critical coronary artery disease and MRI for the exclusion of an acute myocarditis. The recommended therapy and follow-up are essential to achieve the good clinical outcome and avoid complications.