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Varicella zoster encephalitis, cranial nerve neuropathies, and takotsubo syndrome: delving further into the pathogenesis

John E Madias
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DOI: https://doi.org/10.7861/clinmedicine.18-2-190a
Clin Med April 2018
John E Madias
Icahn School of Medicine at Mount Sinai, New York, USA
Elmhurst Hospital Center, Elmhurst, New York, USA
Roles: Division of Cardiology
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Editor – I read with great interest the communication by Bennett and Iqbal,1 published in Clinical Medicine, about the 68-year-old woman with takotsubo syndrome (TTS) secondary to a varicella zoster encephalitis (VZE), and the arduous work of the authors in diagnosing and managing her evolving cranial nerve neuropathies (initially mononeuritis and subsequently polyneuritis), associated with rapid atrial fibrillation, and cardiac abnormalities. The rise in high sensitivity troponin was higher than expected for TTS, and making the distinction between TTS and acute coronary syndromes more difficult. The QRS voltage of the electrocardiogram (ECG) of Fig 1 is low,1 in keeping with TTS,2 and one wonders whether prior to the admission, ECGs, or ECGs from follow-up, showed higher QRS voltages. In reference to the pathophysiology of TTS, we are still far from delineating the underlying mechanism(s), but in cases like the one herein, checking for elevated blood-borne catecholamines,3 or evaluating for evidence of enhanced cardiac autonomic sympathetic nervous system (CASNS) stimulation, norepinephrine-based, exerting cardiomyocyte injury,4 are two promising injurious pathways, needing exploration. Indeed, current commercially available technology5 could provide monitoring of the CASNS function, via the chest electrodes used for ECG recordings, with analysis of filtered signals of 500 to 1,000 Hz from the skin of the thorax, reflecting activity of the stellate ganglia, and the sympathetic autonomic nerve input to the heart.

  • © Royal College of Physicians 2018. All rights reserved.

References

  1. ↵
    1. Bennett L
    , Iqbal J. A 68-year-old with cranial nerve neuropathies and a troponin rise. Clin Med 2017;17:575–7.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Madias JE
    . Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubosyndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28–36.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Wittstein IS
    , Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Samuels MA
    . The brain-heart connection. Circulation 2007;116:77–84.
    OpenUrlFREE Full Text
  5. ↵
    1. Madias JE
    . A proposal for a noninvasive monitoring of sympathetic nerve activity in patients with takotsubo syndrome. Med Hypotheses 2017;109:97–101.
    OpenUrl
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Varicella zoster encephalitis, cranial nerve neuropathies, and takotsubo syndrome: delving further into the pathogenesis
John E Madias
Clinical Medicine Apr 2018, 18 (2) 190; DOI: 10.7861/clinmedicine.18-2-190a

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Varicella zoster encephalitis, cranial nerve neuropathies, and takotsubo syndrome: delving further into the pathogenesis
John E Madias
Clinical Medicine Apr 2018, 18 (2) 190; DOI: 10.7861/clinmedicine.18-2-190a
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