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Curso de Atualização em Medicina Cardiovascular 2019
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05. Atrial Fibrillation
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07. Syncope and Bradycardia
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
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32. Cardiovascular Nursing
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The heart gets the flu
Session:
Sessão de Casos Clínicos - II
Speaker:
Daniel Seabra De Carvalho
Congress:
CPC 2019
Topic:
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Theme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Daniel Seabra De Carvalho; Ana Leal Neto; Inês Pereira Oliveira; Rui Pontes dos Santos; Roncon de Albuquerque; João A. G. Azevedo; Paula Pinto
Abstract
<p>Clinical picture of acute myocarditis may diverge from asymptomatic to cardiogenic shock (CS) and death. Influenza B virus associated with fulminant myocarditis was rarely reported.</p> <p>A 53-years old male, a former smoker with overweight and hypertension, presented at the emergency room with pleuritic chest pain; he was tachycardic, tachypneic with normal blood pressure and no fever; thoracic auscultation revealed normal heart sounds without murmurs and scarce rales in lungs. Electrocardiogram (ECG) showed sinus rhythm with diffuse ST segment elevation; echocardiogram (TTE) revealed edematous pattern of the ventricular walls, moderate compromise of left ventricle (LV) systolic function, mild pericardial effusion; blood analysis revealed troponin I 0.47ng/mL and normal inflammation markers. Due to recurrent chest pain and ECG changes, coronary angiogram was performed and revealed no coronary disease. Myocarditis was suspected and the patient was transferred to the intensive care unit (ICU).</p> <p>Rapid clinical deterioration with CS and severe depression of biventricular global systolic function; initiated inotropic support with dobutamine and noradrenaline without clear improvement of clinical status. The patient was proposed for mechanical circulatory support to the referral center and started veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). Microbiological screening showed the presence of influenza B in the nasal swab and oseltamivir was initiated. His course on VA-ECMO support (12 days) was complicated by right lower limb ischemia and acute renal failure requiring renal function replacement therapy; nevertheless, there was a gradual improvement of global systolic function allowing ECMO withdrawal and the patient was discharged from the ICU. Subsequent cardiac MRI showed mild dilatation of the LV with preserved systolic function and small subepicardial late enhancement spots in the septum and in mid-distal transition of the anterolateral wall compatible with myocarditis. The patient presented digital necrosis in the right foot and was amputated without more complications. Reassessment echocardiogram showed complete recovery of LV ejection fraction.</p> <p>This clinical case emphasize that Influenza B, commonly considered less pathogenic, can be responsible for acute fulminant myocarditis or cardiomyopathy leading to cardiogenic shock in adults. Early aggressive cardiac support and initiation of antiviral treatment are essential for a favorable outcome.</p>
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