View Abstract

A3491 - An Unorthodox Presentation of Acute Myocarditis
Author Block: D. Lai, A. Thomas, N. Ganta; Howard University Hospital, Washington, DC, United States.
Introduction
Early recognition of acute viral myocarditis poses as a challenge to physicians, given its wide spectrum of presentation. Fulminant lymphocytic myocarditis, ironically presents with more acute symptoms and hemodynamic instability, but on the contrary, has a rapid recovery and better prognosis as compared to acute lymphocytic myocarditis.
Case
We describe the case of a 22 year old male with a past medical history of Asthma, tobacco and marijuana use presenting with nausea, vomiting, diarrhea and abdominal pain of 1 day duration. He had associated symptoms of a non-productive cough and exertional dyspnea for a few days. Of significance, he presented to the emergency care area with similar gastrointestinal symptoms 1 month prior, which resolved. Physical examination and vital signs were significant for severe respiratory distress, tachycardia, diminished breath sounds and coarse crepitations. Arterial blood gas highlighted pO2 41 on room air, chest x-ray was significant for findings consistent with Acute Respiratory Distress syndrome. He was subsequently intubated, started on antibiotics and transferred to the intensive care unit. Laboratory findings were significant for leukocytosis with neutrophil predominance, elevated lactic acid and a mild elevation in creatinine. Patient’s peak troponin was elevated at 17.51 and electrocardiogram significant for sinus tachycardia with non-specific ST-T changes prompting further cardiac evaluation. 2D echocardiogram showed severely impaired right and left ventricular systolic function, with an ejection fraction of less than 20%. These findings combined with the clinical picture raised concerns for acute myocarditis. Hence, he was started on ionotropic support with Dobutamine and diuresed appropriately with Furosemide, thereafter commencing Lisinopril and Carvedilol. His hospital course was complicated with barotrauma secondary to mechanical ventilation warranting bilateral chest tube placement. Patient showed marked improvement by day 4 of admission as evident by Chest X-ray, arterial blood gas, troponin and hemodynamic improvement. Viral titers for Cocksackie B were positive confirming the diagnosis of myocarditis.
Discussion
Prior to obtaining Cocksackie B viral titers, an early assessment of myocarditis with management tailored to supportive care and heart failure therapy was initiated, with significant improvement within the span of 4 days. Given such a diverse presentation with the possibility of rapid deterioration and death, physicians should maintain a high index of suspicion for myocarditis especially in previously healthy young patients. Despite a lack of guidelines for management of acute myocarditis, early diagnosis combined with heart failure management and supportive care will potentially improve patient outcome and decrease mortality.