Takotsubo cardiomyopathy associated with Guillain-Barré syndrome: a differential diagnosis from dysautonomia not to be missed

Abstract

A 60-year-old woman presented with a 1-week progressive limb weakness and an areflexic tetraparesis. Both neurophysiological and cerebrospinal fluid examinations were consistent with diagnosis of Guillain-Barré syndrome (GBS) and a treatment by intravenous immunoglobulin over a 5-day period was started. At the end of the treatment, the patient suffered from an acute coronary syndrome (ACS) without stenosis at coronary arteriography. Left ventriculography showed segmental wall motion abnormalities with apical akinesis contrasting with hyperkinesis in basal segments, with a depressed left ventricular ejection fraction at 45%. Cardiac magnetic resonance imaging excluded the diagnosis of myocarditis. A diagnosis of "transient left ventricular apical ballooning syndrome" or "Takotsubo" syndrome was then made and a treatment by angiotensin-converting enzyme inhibitor and beta-blocker was introduced. Left ventricular dysfunction and electrocardiogram normalized within two weeks and the patient remained free from cardiovascular events at one year of follow-up. This cardiomyopathy is a recently known and now commonly diagnosed reversible systolic dysfunction mimicking ACS and is secondary to physical or emotional stress affecting mainly post-menopausal women. Electrocardiographic and echocardiographic abnormalities are often regressive in days or weeks, and rarely responsible for complications. This observation supports clinical evidence that electrocardiographic changes in GBS can be linked to Takotsubo syndrome, by means of the stressful trigger of GBS occurrence. This reversible cardiomyopathy needs adequate management and specific therapeutic strategies. Therefore, trans-thoracic echocardiography should be systematically performed when repolarisation abnormalities are present in this disease to rule out a Takotsubo syndrome, even in asymptomatic patients.