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A5264 - Respiratory Syncytial Virus Associated Myocarditis Requiring Veno-Arterial Extracorporeal Membrane Oxygenation
Author Block: A. Milas1, N. Anand1, M. Saunders-Kurban2, S. Patel1; 1Advocate Christ Medical Center, Oak Lawn, IL, United States, 2Mercy Health, Grand Rapids, MI, United States.
Introduction:Respiratory syncytial virus (RSV) is a very rare infectious culprit infrequently described in the medical literature as a cause for myocarditis, particularly in adults. We present a case of acute fulminant myocarditis in a patient with PCR positive RSV infection requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO).
Case:Our patient was a 40-year-old African American male with a past medical history of diabetes, hypertension and hyperlipidemia who was in his normal state of health prior to admission. He recently traveled from Las Vegas and upon returning, abruptly developed fevers, chills and worsening dyspnea. He had no prior cardiac or pulmonary disorders. On presentation, the patient was found to be febrile, tachycardiac, and tachypneic. Labs were remarkable for an elevated troponin, beta-natriuretic peptide, lactic acid, and white blood cell count. Electrocardiogram demonstrated tachycardia and T-wave inversions in leads V4 through V6. Chest x-ray showed bilateral interstitial infiltrates and the patient subsequently required mechanical ventilation secondary to worsening hypoxemic respiratory failure. Bronchoalveolar lavage was positive for respiratory syncytial virus, subtype A.
Given his worsening hypotension and impending cardiogenic shock, the patient underwent cardiac catheterization yielding non-obstructive coronary disease. Due to his progressive cardiopulmonary failure despite maximum vasopressor support and intra-aortic balloon pump placement, the patient required VA-ECMO. An intraoperative transesophageal echocardiogram showed severely depressed left ventricular systolic function in the range of 10-15%. Explantation from VA-ECMO occurred 20 days post-operatively. Follow up echocardiogram showed improvement in his ejection fraction to 35-40%. Repeat cardiac biomarkers trended downward and were within normal limits at this time indicating myocardial recovery. Comprehensive viral panels were all negative except for persistently positive RSV subtype A on RT-PCR. Further workup for other etiologies yielded widely negative results including autoimmune or toxin-induced myocardial injury.
Discussion:Myocarditis is an inflammatory cardiomyopathy that may present with new onset cardiac dysfunction ranging from subclinical to cardiogenic shock. The major causes of myocarditis include viral and bacterial infections, systemic autoimmune diseases and various toxins. Treatment typically focuses on alleviation of heart failure symptoms with medication and supportive care. For patients with progressive disease refractory to medical therapy, circulatory support can be provided with left ventricular assist devices. There is a paucity of literature describing RSV in correlation with fulminant myocarditis, especially in adults. We stress the importance of considering RSV as a possible cause of rapidly fulminant myocarditis and underscore the need for aggressive treatment with VA-ECMO for refractory cardiogenic shock.