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BIOPSY PROVEN ACUTE IDIOPATHIC LYMPHOCYTIC MYOCARDITIS PRESENTING WITH PROGRESSIVE HEART BLOCK, HEART FAILURE, AND CARDIOGENIC SHOCK
Abstract   Open access   Peer reviewed

BIOPSY PROVEN ACUTE IDIOPATHIC LYMPHOCYTIC MYOCARDITIS PRESENTING WITH PROGRESSIVE HEART BLOCK, HEART FAILURE, AND CARDIOGENIC SHOCK

Amir Harb, Parikshit Chapagain, Tareq Alsaleh, Nouman Shafique, Zhijian He and Daniel Tambunan
Journal of the American College of Cardiology, Vol.85(12 Suppl), pp.3892-3892
04/01/2025
DOI: 10.1016/S0735-1097(25)04376-1
url
https://doi.org/10.1016/S0735-1097(25)04376-1View
Published (Version of record) Open Access

Abstract

Background Acute idiopathic lymphocytic myocarditis (AILM) can present as conduction disease or as acute coronary syndrome. Here we present a case of AILM that developed progressive heart block requiring transvenous cardiac pacing and heart failure resulting in cardiogenic shock. Case A woman in her late 30ʼs with no medical history presented to the ED with two days of vomiting, fatigue, shortness of breath. She was tachycardic on admission. Labs showed NT-proBNP 4,279, hs-cTn trend 729/667/613, CRP 8, ESR 17, D-dimer 3.88 but negative CT-pulmonary angiography and a drug screen positive for amphetamines. Transthoracic echocardiogram showed a normal left ventricular ejection fraction, increased left ventricular wall thickness, and a small pericardial effusion without evidence of tamponade. ECG indicated sinus tachycardia with right bundle branch/left anterior fascicular block and anterolateral ST depressions with T wave inversions that developed into third-degree atrioventricular block requiring transvenous cardiac pacing. Left heart catheterization revealed basal inferior wall hypokinesis with normal coronary arteries. She began to decompensate, and a cardiac MRI was obtained which indicated an ejection fraction of 44%, biventricular dysfunction, and evidence of mild myocarditis. She developed cardiogenic shock, was started on furosemide and milrinone drips, and an intra-aortic balloon pump was placed. Tissue exam of endomyocardial biopsy samples showed inflammatory infiltrate of lymphocytes but was negative for a viral cytopathic effect, granulomas, giant cell myocarditis, and amyloid. She was started on IV methylprednisolone with taper for myocarditis. Decision-making The biggest challenges were considering the earlier use of cardiac MRI to expedite risk stratification and management and anticipating the need for hemodynamic support. Conclusion AILM can present with acute life-threatening cardiac syndromes. Though the use of cardiac MRI is ever increasingly enabling earlier diagnosis, prompt endomyocardial biopsy remains the gold standard for diagnosis and should be considered especially early in fulminant cases potentially developing cardiogenic shock.

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