A 63-year-old male, with a past medical history (PMHx) of recurrent abdominal adhesions requiring multiple surgeries, presently with Abcarian stoma and mucus fistula, presented with a history of abdominal pain and fever. The results of his initial physical examination revealed a body temperature of 36.8 C, a blood pressure of 109/54 mmHg, a pulse rate of 109 beats/min, and a respiratory rate of 18 breaths/min. The breathing sound was coarse; his heartbeats were regular without audible murmur; the abdomen was soft with tenderness in the right upper quadrant, with positive murphy signs. There was no palpable mass or hepatosplenomegaly noted.
The initial blood investigations revealed mild anemia, hemoglobin level of 10.6g/dl, with marked neutrophilic leuocytosis, white blood cell count of 28,000/ml. The C-reactive protein level was 100 mg/L. His troponin I level was mildly elevated at 48 ng/L. Renal function was deranged with a creatinine level of 176 umol/L and urea of 19 mmol/L. Other laboratory findings, including electrolytes, liver function tests, serology, and urinalysis, were all within normal limits. Chest X-ray findings were unremarkable, as was the initial ECG. Ultrasound of abdomen showed thick gallbladder wall greater than 3mm, with pericholecystic fluid. There was also evidence of sludge and cholelithiasis.
He was admitted with the impression of sepsis secondary to acute cholecystitis. He was started on antibiotics along with other supportive measures. On the next day, the patient continued to be highly febrile and became hypotensive requiring intensive care unit (ICU) admission and inotropic support.
On the 2nd day of ICU admission, he started complaining of retrosternal chest pain which was associated with profuse sweating. ECG was notable for ST-segment elevation on leads V2-V4 [Figure 1]. The patient's troponin-T level was elevated at 781 ng/L. A diagnosis of anterior wall ST-segment elevation myocardial infarction was considered. An emergent coronary angiography was done which demonstrated nonobstructive CAD. Echocardiographic evaluation revealed dilated left ventricular cavity with extensive apical dyskinesis and relative preservation of the basal to midseptal and basal-lateral wall contraction [Figure 2]. Estimated left ejection fraction was approximately 25%. Sepsis-induced TCM was the final diagnosis in this patient. The patient recovered after antibiotics and other conservative therapies, and finally, he was discharged from the hospital. He had repeated echocardiogram 4 weeks later which showed complete resolution of left ventricular systolic function, estimated ejection fraction was >55%.