An unusual cause of dyspnea: giant hiatal hernia followed by Takotsubo cardiomyopathy.

Patients with acute dyspnea are a challenging issue to physicians. For such cases, rapid evaluation and management to achieve a stable hemodynamic status is very important. Initially, a tentative diagnosis depends on the presentation and brief history-taking. Here, we present the case of a patient who complained of dyspnea. Giant hiatal hernia and Takotsubo cardiomyopathy have been regarded as sequential causes of the dyspnea. The patient is an 86-year-old female who had a history of hypertension, old cerebral vascular disease, and chronic obstructive pulmonary disease. She presented to the emergency department with shortness of breath for 1 day. On arrival, the results of her physical examination were unremarkable except for a bilateral wheezing breathing sound. A 12-lead electrocardiogram showed sinus tachycardia. Her chest X-ray scan showed cardiomegaly and mediastinum widening (Fig. 1A), and the chest computed tomography showed hiatal hernia with distended intrathoracic stomach and esophagus (Fig.1B and C). She was treated with intravenous hydration and nebulized bronchodilator. Owing to respiratory failure, an endotracheal tube was inserted. Two days later, she was extubated smoothly. Unfortunately, respiratory failure again occurred on the 6 hospital day. Her electrocardiogram showed inverted T waves over the precordial leads, whereas the cardiac enzyme results showed myocardial injury with a maximal troponin I of 3.74 ng/mL. Her coronary angiography revealed nonobstructive coronary artery and left ventricle with apical ballooning (Fig. 1D). One month later, she was discharged with tracheostomy and feeding jejunostomy. Dyspnea is not widely recognized as a main symptom of hiatal hernias [1]. Patients with large hiatal hernias may have significant dyspnea and exercise impairment. The