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A severe case of myocarditis
Session:
Casos Clinicos
Speaker:
Guilherme Lourenço
Congress:
CPC 2020
Topic:
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Theme:
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Subtheme:
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Session Type:
Comunicações Orais
FP Number:
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Authors:
Guilherme Lourenço; Catarina Perez Brandão; Conceição Trigo; José Diogo Ferreira Martins; Maria De Fátima Pinto
Abstract
<p>Giant Cell Myocarditis (GCM), unlike most forms of viral myocarditis, is a rapidly progressive disease,<br /> and fatal if untreated. Even though GCM is rare its diagnosis is crucial, since initiation of<br /> immunosuppressive therapy can be very effective.</p> <p>A previously healthy 15-year-old male was admitted to our department with a history of two weeks of<br /> chest pain, fatigue, dyspnoea, and dry cough. He had acute otitis one week before the onset of<br /> symptoms.<br /> On presentation he was haemodynamically stable, had good peripheral perfusion, and basal rales on<br /> lung auscultation. ECG showed sinus tachycardia and diffuse T wave inversion; troponin I and BNP<br /> levels were elevated (see figure 1). An echocardiogram was performed, demonstrating a structurally<br /> normal heart and left ventricular (LV) systolic dysfunction, with an ejection fraction (EF) of 47%.<br /> Diagnostic workup for myocarditis aetiology was initiated, and the patient was started on enalapril and<br /> carvedilol.<br /> In the next days, symptoms and LV function worsened (EF 25%). He was then admitted to the Intensive<br /> Care Unit (ICU) and started on dopamine and milrinone, and EF increased to 43%. In spite of inotrope<br /> support and one levosimendan cycle there was clinical worsening with decreasing LV function (EF 31%,<br /> global longitudinal strain -5.5%) and increasing troponin and BNP levels (maximum 18287 and 3929<br /> pg/mL respectively). An endomyocardial biopsy (EMB) was performed, which revealed an inflammatory<br /> infiltrate with eosinophil predominance and with presence of giant multinucleated cells.<br /> Triple immunosuppression was started with prednisolone, azathioprine and cyclosporine. There was a<br /> significant improvement in the following days, with progressive improvement of LV function and<br /> biomarkers and subsiding of symptoms in two weeks, allowing weaning of inotropic support. The patient<br /> was discharged home one month later, in NYHA class 2, with troponin I of 55pg/mL, BNP 305pg/mL,<br /> normalization of ECG abnormalities, and EF of 53%, with fibrosis but without segmental contractility<br /> abnormalities on MRI. He has been stable since (6 months follow up time).<br /> </p> <p>This case illustrates the need for EMB, although sensitivity is not perfect. Even though this patient is now<br /> well, GCM has a poor prognosis, with average time to death/transplant less than one year.</p>
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