Myocarditis

Fri, 12/11/2020 - 6:05am
Author: 
Katie Nowlan, MD
Editor: 
John Cafaro MD

HPI 

 A 24 y.o.female with past medical history of C-section (2 years ago) presented to the ED of an OSH complaining of chest pain.  Patient was in her normal state of health recently until 3 days ago when she began having intermittent, diffuse, midsternal, non-radiating chest pain associated with shortness of breath and subjective fevers.  Pain is aggravated by nothing but relieved somewhat by leaning forward.  Patient also states she had some nausea and NBNB vomiting of approximately 5 episodes during the last 3 days and after the first episode of vomiting she also began to have intermittent non-radiating epigastric pain.  Denies diarrhea, urinary complaints, or any recent abdominal or chest trauma.  Of note patient states she was tested positive for COVID-19 in April 2020 (6 months ago).  She was not hospitalized and recovered without incident per patient report. 

OSH ED Course 

She was found to have elevated troponins that trended 17.6 ->14.02 -> 9.95 as well as an elevated BNP of 14900.  Her EKG was notable for sinus tachycardia with a rate of 110, right bundle branch block, non-specific T wave changes in inferior leads, but no ST elevations or depressions.  She was also found to have elevated transaminases (ALT 139, AST 235) and concern for cholecystitis.  She had a CT of her abdomen pelvis as well as a CT chest angio.  Her imaging revealed no evidence of acute pulmonary embolism however she did have a small right pleural effusion, edematous gallbladder and a small pericardial effusion.  She was negative for influenza, covid, and hCG.  She received ketorolac 15 mg IV as well as 1 dose of IV azithromycin, IV Rocephin and IV Flagyl (covered for pneumonia and cholecystitis).  While she was in the ED she became hypotensive to the 80s and was started on a Levophed drip and transferred to CUH with the gtt infusing at 5 mcg/min.  On arrival to the ICU, POC echo shows a decreased EF as well as a small pericardial effusion but not concerning for tamponade physiology. 

Rapid fire review of  myocarditis: 

  • Pathophysiology:  Inflammation of the heart muscle itself, most frequently by focal infiltration of the myocardium by lymphocytes, plasma cells, and histiocytes (which is why the gold standard for diagnosis is biopsy). 

  • Most common causes:   

  • Viral:  coxsackie, echovirus, influenza, parainfluenza, EBV, Hep B, HIV 

  • Bacterial: corynebacterium diphtheriae, neisseria meningitidis, mycoplasma pneumoniae, B-hemolytic strep, lyme disease 

  • Clinical features:  fever, headache, myalgias, tachycardia (that’s out of proportion to fever), chest pain, +/- symptoms of HF 

  • Diagnosis:  It can be diagnosed clinically however all diagnostics are non-specific (non-specific ST-T-wave changes, ST-segment elevations with PR depressions, trops and pro-BNP may be elevated, echo may have myocardial depression).  Some institutions are beginning to use cardiac MRI and PET scans. 

  • Treatment:   

  • Supportive for viral

  • Antibiotics for bacterial

  • Avoid NSAIDs (unlike pericarditis, NSAIDs are not effective and can actually enhancemyocarditic process and increase mortality)

  • Immunosuppressive therapy for severe cases

  • Cardiomyopathy/HF standard of care tx (diuresis,beta-blocker, +/- ACE-I)

New HF and gallbladder edema? 

  • Fluid overload can manifest with congestive hepatopathy and edematous gallbladder that can mimic acalculous cholecystitis 

 

A word on the relationship of myocarditis/myocardial injury and SARS-CoV-2 

  • has not been definitively confirmed by myocardial histologic and viral genome analysis 

  • Insufficient evidence, further investigation needed 

  • Only case studies thus far 

  • From this case:  Cardiology thought that this patient’s myocarditis with new onset HF less likely to be related to covid given she was 6 months out and more likely related to another viral illness (which the patient could not recall/identify) 

 

Back to the case: 

She was successfully weaned off vasopressors and down-graded to med/tele.  Her transthoracic echo confirmed a cardiomyopathy with acute HFrEF with EF 30% with global hypokinesis of LV, and grade I diastolic dysfunction.  Cardiology was consulted and she was started on a furosemide and metoprolol.  Did not start ACE-I due to blood pressure.  She had a cardiac MRI that showed findings consistent with myocarditis.  In regards to her edematous gallbladder, a RUQ confirmed hepatic congestion consistent with volume overload secondary to HF and no acute cholecystitis.  She was discharged home after three days. 

 

 References: 

  1. “Cardiomyopathies with Systolic and Diastolic Dysfunction.” Tintinalli's Emergency Medicine: a Comprehensive Study Guide, by David Cline et al., McGraw-Hill Education, 2020, pp. 381–383. 

  1. Ford RM, Book W, Spivey JR. Liver disease related to the heart. Transplant Rev (Orlando). 2015 Jan;29(1):33-7. doi: 10.1016/j.trre.2014.11.003. Epub 2014 Nov 18. PMID: 25510577. 

  1. Zenda T, Araki I, Nakamiya O, Ogawa M, Higashi K, Ueno T. Acute peri-myocarditis with an unusual initial manifestation of gallbladder edema and a profound eosinophilic surge during convalescence. Fukushima J Med Sci. 2018;64(2):95-102. doi:10.5387/fms.2018-08 

“Treatment and Prognosis of Myocarditis in Adults.” UpToDate, 2019, www.uptodate.com/contents/treatment-and-prognosis-of-myocarditis-in-adul....