Takotsubo cardiomyopathy associated with Protobothrops mucrosquamatus envenomation: a case report

TL;DR

A patient bitten by a Taiwan habu snake developed Takotsubo cardiomyopathy, a heart condition usually caused by stress, and was successfully treated with anti-venom and supportive care.

Contribution

First reported case of Takotsubo cardiomyopathy caused by Protobothrops mucrosquamatus snake venom.

Findings

Takotsubo cardiomyopathy can be triggered by Protobothrops mucrosquamatus envenomation.

Early diagnosis using echocardiography and coronary angiography is critical due to symptom overlap with heart attacks.

Anti-venom serum and fluid resuscitation are effective in treating this condition.

Abstract

Protobothrops mucrosquamatus, commonly known as the Taiwan habu, is a highly venomous snake species. Its venom is rich in haemotoxins and neurotoxins, capable of inducing severe coagulopathy, tissue necrosis, and multi-organ damage. However, to date, there have been no reported cases of Takotsubo cardiomyopathy (TTS) triggered by envenomation from P. mucrosquamatus. TTS is characterised by transient left ventricular dysfunction precipitated by acute stress events and is typified by abnormalities in left ventricular wall motion, often mimicking the clinical presentation of coronary artery disease.

This report presents a rare case of Takotsubo cardiomyopathy (TTS) triggered by envenomation from P. mucrosquamatus. Following the snakebite, the patient rapidly developed severe pain and bleeding at the bite site, and subsequently experienced acute chest tightness and chest pain during hospitalisation. To elucidate the aetiology, the patient underwent a series of investigations, including electrocardiography, transthoracic echocardiography, and coronary angiography, which ultimately confirmed the diagnosis of TTS. The patient received comprehensive treatment comprising administration of anti-venom serum to neutralise the venom, fluid resuscitation, and antiplatelet therapy. The clinical condition gradually stabilised, and the patient was eventually discharged in good health.

Protobothrops mucrosquamatus envenomation may precipitate Takotsubo cardiomyopathy (TTS). Given the considerable overlap in early clinical presentation between TTS and acute myocardial infarction (AMI), early utilisation of echocardiography, coronary angiography, and fractional flow reserve (FFR) assessment is crucial for accurate diagnosis. The cornerstone of treatment lies in the prompt and adequate administration of anti-venom serum, combined with fluid resuscitation and supportive symptomatic care. The judicious use of antiplatelet agents after restoration of coagulation function is generally considered safe and does not significantly increase the risk of bleeding.

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