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Global Translational Medicine Complication of carbon monoxide poisoning

nausea, difficulty in concentration, confusion, shortness of the mid-apical segments of the left ventricle with a
of breath, visual changes, chest pain, loss of consciousness, slightly reduced global systolic function (EF 50%); these
abdominal pain, and muscle cramping. Severe CO poisoning findings were compatible with the diagnosis of Takotsubo
can cause skin lesions (cherry-red erythema, vesicles, bullae, cardiomyopathy (Figure 1B). After the initial stabilization,
and cutaneous necrosis); these lesions are often misdiagnosed the patient was transferred to the geriatric department, and
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as burns. Takotsubo cardiomyopathy is a form of non-ischemic a week later, troponin I, CPK, lactate, and cardiac kinetics
cardiomyopathy, characterized by transient regional systolic normalized (Figure 1C). The submammary cherry-red skin
dysfunction of the left ventricle mimicking acute myocardial lesion partially healed (Figure 1D), and a skin biopsy was
infarction but with only minimal release of cardiac enzymes. not performed due to a lack of consent. The myocardial
The term “Takotsubo” means octopus trap in Japanese, as the perfusion imaging test (SPECT) result (Figure 1E) was
shape resembles the systolic apical ballooning appearance of negative for myocardial ischemia.
the left ventricle. 4
3. Discussion
2. Case presentation
Takotsubo cardiomyopathy is a syndrome characterized by
An 83-year-old female patient, diagnosed with Alzheimer’s transient left ventricular dysfunction (hypokinesia, akinesia,
dementia and Type 2 diabetes mellitus, was transported to or dyskinesia), usually presenting as apical ballooning or
the emergency department by ambulance due to impaired midventricular, basal, or focal wall motion abnormalities
consciousness. Her caregiver reportedly discovered the that extend beyond a single epicardial vessel territory. New
patient unconscious, sitting in the wheelchair with vomit on ECG abnormalities (ST-segment elevation or depression,
her clothes, in the morning. The heating in the apartment T-wave inversion, and rate-related [or corrected] QT
was powered by liquefied petroleum gas. On admission interval [QTc] prolongation) and mild increases in
to the emergency department, the reported vital signs of troponin levels are common. Takotsubo usually affects
the patient were as follows: blood pressure, 110/67 mmHg; postmenopausal women with ischemic-like chest pain and
body temperature, 36°C; heart rate, 90 beats/min; and is strongly correlated with physical and emotional stress.
respiratory rate, 22 breaths/min. Physical examination Although most patients present with a complete recovery,
revealed mild dyspnea, warm and dry skin with a cherry- mortality is higher than previously thought. According
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red lesion in the submammary area, rhythmic heart to a 2016 study by Sung et al., 30% of patients affected by
action, a normal vesicular murmur over the entire lung CO intoxication report myocardial damage; 25.6% of these
area, and a Glasgow Coma Scale score of 8 (E2-V2-M4). patients had normal echocardiography; 51.2% presented
The electrocardiogram (ECG) revealed sinus rhythm at 90 with global changes in left ventricular kinetics; and 23.2%
bpm, with normal ST segment and T waves. Additionally, had Takotsubo-like cardiomyopathy. The abnormalities of
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the arterial blood gas analysis in ambient air was as follows: Takotsubo CO-related cardiomyopathy are thought to be
pH 7.32; pCO 31 mmHg; pO 60 mmHg; HCO 16 mmol/L; caused by an increase in catecholamines and consequent
2:
3:
2:
COHb: 23.8%; and lactate: 10.5 mmol/L. Laboratory test myocardial stunning. This condition is usually transient
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results were as follows: creatinine: 1.12 mg/dL; creatine and is managed with supportive care, but some patients
phosphokinase (CPK): 2352 U/L; myoglobin: 1141 ng/mL; require intensive care due to acute complications such as
and troponin I: 3276 ng/L. A head computed tomography cardiogenic shock or acute heart failure; in patients with
revealed age-compatible brain atrophy. Following the severe left ventricular systolic dysfunction, the risk of left
diagnosis of CO poisoning, the patient was admitted to the ventricular thrombosis and systemic embolization should be
emergency medicine ward. Subsequently, the patient was considered. Rhabdomyolysis is characterized by an elevation
administered O via continuous positive airway pressure in CPK due to the damage to striated muscle fibers and the
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(CPAP), with a FiO of 50% and a positive pressure of 7.5 cm consequent release of intracellular muscular constituents
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H O. Large volumes of crystalloids were administered to into the blood circulation. This complication is reported
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prevent renal damage due to rhabdomyolysis, and low- in approximately 30% of patients with CO intoxication;
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molecular-weight heparin (LMWH) was administered for among non-traumatic causes of rhabdomyolysis, CO
antithrombotic prophylaxis. Hyperbaric O therapy was intoxication represents 3.2% of the total number of cases.
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deemed unnecessary by the poison control center. The In CO poisoning, muscle compression, caused by the
CPAP rapidly reduced COHb levels (1.6% after 4 h and patient’s own weight, increases the pressure within the
0.3% after 5 h). On the following day, we found changes muscle compartment, causing edema and ischemia. If this
in the ECG, specifically the appearance of negative T condition persists, COHb production increases and the
waves in the precordial leads (V1–V6) (Figure 1A). The O supply further decreases, leading to necrosis of muscle
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bedside echocardiogram showed akinesia and dilatation fibers and rhabdomyolysis. Numerous CO-related skin
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Volume 3 Issue 1 (2024) 2 https://doi.org/10.36922/gtm.1718