Simultaneous occurrence of myocardial infarction and duodenal perforation

Excerpt

An 81-year-old woman with no cardiovascular risk factors, but with a family history of thrombosis (her brother died from pulmonary thromboembolism), was admitted after experiencing tarry stools for the previous month. She had also experienced sudden onset severe abdominal pain. Physical examination showed pallor of the face and severe abdominal tenderness. Computed tomography indicated ascites and abdominal free air, suggesting gastrointestinal perforation (Fig. 1a). Laboratory data showed severe anemia (Hb 4.6 g/dl), low antithrombin activity (51%), normal disseminated intravascular coagulation (DIC) score (4 points), and normal troponin-I and creatine kinase level, suggesting an antithrombin deficiency irrelevant to DIC. Although she reported no chest pain, an electrocardiogram was performed, which showed normal sinus rhythm and ST segment elevation in the inferior and lateral leads (Fig. 1b). Echocardiography showed inferior, posterior, and apical hypokinesis with an ejection fraction of 40%, suggesting acute myocardial infarction. An emergency coronary angiography was performed, and a normal right coronary artery and multiple left coronary thromboses were identified (Fig. 1c); atherosclerosis was not detected by intravascular ultrasound. A thrombectomy was performed and coronary flow was improved. After the thrombectomy, laboratory data showed elevated cardiac enzymes (troponin-I 50 ng/mL and creatine kinase: 1800 U/L), suggesting an acute phase of myocardial infarction. Because of unstable hemodynamics, the gastrointestinal perforation was treated conservatively. She died 19 days later of multiple organ failure. An autopsy revealed colon carcinoma, in addition to duodenal perforation (Fig. 1d), and inferior and posterior myocardial infarction. Duodenal perforation was not ischemic, but digestive. No other condition that would lead to coronary thrombosis, such as left atrial thrombosis or right-left shunt, was detected.

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