Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy
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Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial symptoms and underscores the importance of rapidly recognizing this disorder.
KeywordsPostpartum cardiomyopathy Neuropathy Rhabdomyolysis
Our patient presented with symptoms and signs of rhabdomyolysis and peripheral neuropathy. These two distinct disease entities are rarely encountered in combination. In our case rhabdomyolysis and peripheral neuropathy were attributed to one common cause, namely ischaemia due to acute arterial thromboembolism as a complication of PPCM . This diagnosis was delayed because the cardiovascular symptoms were not immediately recognized.
Cardiovascular disease is rare in women of childbearing age. In the general population arterial thrombosis is most commonly caused by atherosclerosis. However, in young women other mechanisms may play a role, especially in the absence of multiple risk factors for atherosclerosis like a family history of (premature) atherosclerosis, smoking, diabetes mellitus and obesity . First a status of hypercoaguability should be considered, for example due to the antiphospholipid syndrome or hyperhomocysteinaemia [3, 4]. The relation between arterial thrombosis and the heritable thrombophilias factor V Leiden mutation, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency are less well established . Also pregnancy induces a state of hypercoaguability, due to the fact that most clotting factors increase during pregnancy and fibrinolytic activity is decreased . Although pregnancy by itself usually does not lead to (arterial) thrombosis, the concurrence of pregnancy with other risk factors for thromboembolism can disclose serious cardiovascular disease .
Arterial thromboembolic events in young patients may also occur due to structural abnormalities of the heart . Prosthetic heart valves or valvular heart disease as a result of congenital abnormalities or rheumatic heart disease are most common. In young patients also a patent foramen ovale should be considered leading to a so-called paradoxical embolus which originates from the venous circulation . Finally, intracardiac thrombosis due to atrial fibrillation or severe dysfunction of a ventricle as a result of cardiomyopathy may be the origin of arterial thromboembolism. In fact, the latter was the case in our patient.
Our patient meet the criteria for PPCM as set forth by Demakis . PPCM is observed in 1 of 3,000–4,000 live births  and mortality is approximately 15% despite optimal treatment . Preeclampsia is a known risk factor for PPCM . Patients most commonly present with signs and symptoms of systolic heart disease, but with (unnoticed) progression of the disease the heart may dilate and thrombus formation in the ventricles may occur. Neurological symptoms can arise in case of cerebral embolization , but also thromboembolism in the lower extremities has been described . Therefore, as is also demonstrated in our case, PPCM may present with predominantly non-cardial symptoms.
In conclusion, the unusual combination of rhabdomyolysis and peripheral neuropathy in a patient should urge on doctors to look for a common vascular cause. The early recognition of arterial thromboembolism as a result of PPCM may prevent further morbidity and mortality of this disease.
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Open AccessThis is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (https://creativecommons.org/licenses/by-nc/2.0), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.