European Journal of Echocardiography Advance Access originally published online on June 23, 2008
European Journal of Echocardiography 2008 9(5):585-586; doi:10.1016/j.euje.2007.06.010
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Bloodletting-induced cardiomyopathy: reversible cardiac hypertrophy in severe chronic anaemia from long-term bloodletting with cupping
Il-Suk Sohn1,*,
Eun-Sun Jin1,
Jin-Man Cho1,
Chong-Jin Kim1,
Jong-Hoa Bae1,
Ju-Young Moon2,
Sang-Ho Lee2 and
Myung-Jae Kim2
1 Cardiovascular Center Kyunghee East-West Neo Medical Center, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, South Korea
2 Department of Nephrology Kyunghee East-West Neo Medical Center, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, South Korea
Received 7 June 2007; accepted after revision 20 June 2007; online publish-ahead-of-print 23 June 2008.
* Corresponding author. Tel: +82 2 440 6108; fax: +82 2 442 6638. E-mail address: issohn89{at}hanmail.net
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Abstract
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Cardiac hypertrophy in a patient with severe iron deficiency
anaemia associated with long-term bloodletting using cupping,
called ‘puhang’ in oriental medicine, is discussed
using chest electrocardiographic and radiographic images. With
iron supply, the patient showed remarkable improvement of cardiomegaly,
which is a unique feature of chronic severe iron deficiency
anaemia.
Keywords: Anaemia; Cardiomyopathy; Heart failure
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Case report
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A 66-year-old woman presented with resting dyspnoea and fatigue.
Physical examination revealed marked pallor of skin and conjunctiva,
both neck vein engorgements, crackles on both lower lung fields,
rapid regular heart beats without murmur, and pitting oedema
of both lower extremities. The electrocardiography showed normal
sinus rhythm, poor R-wave progression, and low voltage in chest
leads at a rate of 94 b.p.m. The chest radiograph showed marked
cardiomegaly and mild pulmonary oedema with left-sided pleural
effusion (
Figure 1A). The initial haemoglobin level was
1.5 g/dL, the haematocrit level was 5.1%, the mean corpuscular
volume was 60.4 fL, and the mean corpuscular haemoglobin concentration
was 29.9 g/dL. The iron studies resulted in severe iron deficiency
anaemia, with an iron level of 9 µg/dL, total iron-binding
capacity, 391 µg/dL; ferritin, 6.8 ng/mL; and reticulocyte
count, 10.3%. The peripheral blood smear showed microcytic hypochromic
anaemia with anisopoikilocytosis and no malignant cells. The
level of N-terminal pro B-type natriuretic peptide was remarkably
elevated, at 6177.1 pg/mL. Echocardiography revealed mildly
dilated left ventricular (LV) chamber size with concentric LV
hypertrophy with moderate amount of pericardial effusion (
Figure 2A).
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Figure 1 (A) The initial chest radiography showed marked cardiomegaly and mild pulmonary oedema with left-sided pleural effusion. (B) On 3 month follow-up, radiograph revealed regressed cardiomegaly and pleural effusion.
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Figure 2 (A) The initial echocardiography revealed mildly dilated left ventricular (LV) chamber size (LV end-diastolic dimension, 5.6 cm; end-systolic dimension, 3.7 cm) with concentric LV hypertrophy, left atrial enlargement, hyperdynamic wall motion with preserved LV systolic function, moderate amount of pericardial effusion, and mild mitral and tricuspid regurgitation with a estimated pulmonary arterial systolic pressure of 55 mmHg. (B) On 3 month follow-up echocardiogram showed normalized LV wall thickness and dimension, scanty pericardial effusion, and trace mitral and tricuspid regurgitation without evidence of pulmonary hypertension.
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She had used cupping, called ‘puhang’ in oriental
medicine, at home for more than 10 years for relief of non-specific
pains. Puhang is often used on the acupuncture points to remove
‘bad’ blood (a bloodletting type).
The patient was given lisinopril, furosemide, and oral iron sulfate and discharged with a prescription for lisinopril and iron sulfate on the 12th days of hospitalization. After 3 months, she was free of signs and symptoms of cardiac failure. Her haemoglobin and haematocrit levels had normalized. Marked cardiomegaly on the chest radiograph also had regressed (Figure 1B). A follow up echocardiogram revealed normalized LV wall thickness and dimension with scanty pericardial effusion and trace mitral regurgitation (Figure 2B).
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References
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- Varat MA, Adolph RJ, Fowler NO. Cardiovascular effects of anemia. Am Heart J (1972) 83:415–26.[CrossRef][Web of Science][Medline]
- Hegde N, Rich MV, Gayomali C. The cardiomyopathy of iron deficiency. Tex Heart Inst J (2006) 33:340–44.[Web of Science][Medline]
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Abstract
Case report