A Case of Dilated Cardiomyopathy with Massive Left Ventricular Thrombus after Use of a Sibutramine-Containing Slimming Product
A 32-year-old man was admitted with progressively worsening dyspnea on exertion of 1 month duration. The patient was not known to have hypertension, diabetes or any other medical illness. He reported having taken the unauthorized health product, "Slim-30", for the last 7 months and had stopped taking it 2 weeks ago. Several medicines regulatory authorities are warning that this product contains an undeclared pharmaceutical ingredient, N-desmethyl sibutramine, an analogue of sibutramine, which has now been banned because of cardiovascular adverse effects. When the drug was first started, his body mass index was 26.3. From the outset the patient presented higher blood pressure and palpitation, therefore he had taken the pill at intervals of about 2 to 3 days. On admission, initial vital signs were as follows: blood pressure of 110/80 mm Hg, pulse rate of 130 beats/min, respiration rate of 20 breaths/min, and body temperature of 36.5℃. Upon physical examination, pitting edema in both lower extremities was noted and a S3 gallop sound was audible. Chest X-ray showed cardiomegaly (cardiothoracic ratio was 0.60) and no pulmonary edema (). The electrocardiogram showed sinus tachycardia with diffuse non-specific ST segmental changes. The cardiac enzymes were within the normal range with a Troponin-T level of 0.023 ng/mL (normal ≤0.100) and creatine kinase-MB level of 1.86 ng/mL (normal ≤4.94). However, pro-B-type natriuretic peptide level was elevated to 5404 pg/mL (normal ≤88). A complete blood cell count, coagulation profile, and thyroid function test were within normal limits. Liver enzymes were elevated with an aspartate aminotransferase level of 80 IU/L and alanine transaminase level of 120 IU/L. The transthoracic and transesophageal echocardiogram revealed dilated LV (end-diastolic diameter of 6.5 cm) with severely impaired systolic function {ejection fraction (EF) of 23%} and multiple hyperechoic, pedunculated masses attached to the LV apical wall, of which the largest measured 4.6×1.5 cm in size (). In the presence of severe LV systolic dysfunction, the mass-like lesions were suspected of thrombi. The patient was started on diuretics, angiotensin-converting-enzyme inhibitor (ACEI) and parenteral unfractionated heparin. He had a good clinical response to treatment and subsequent echocardiogram performed 10 days later showed that LV thrombi had nearly dissolved, although there was only a slight improvement in LV dilatation and contractility. Multi-detector computed tomographic coronary angiography, which was performed before discharge, showed normal a coronary artery (). He was discharged in a stable condition and prescribed a beta blocker, ACEI, and oral warfarin. At 1 month follow-up, echocardiogram demonstrated complete resolution of LV thrombi and markedly improved LV systolic function (EF of 45%) and dilatation (end-diastolic diameter of 5.6 cm) (). The patient is currently doing well and is being followed up via the outpatient department.