Title: It’s Not Always GERD: A Case of Idiopathic Myocarditis
Author(s): Farah Naz Taufiq, MD; Stanley Ozogbo, MD; Stephen Pupillo, DO
Email: FTaufiq@mercy.com
Introduction: Myocarditis is inflammation of the myocardium that can be caused by different infectious and noninfectious etiologies. Myocarditis can present with nonspecific symptoms. Here we present a case of idiopathic myocarditis presenting with burning chest pain and severely elevated troponin.
Case Report(s): A 19-year-old African American male presented to the emergency department with 5 days of burning chest pain. Located in the middle of his chest, the pain was intermittent, non-radiating, associated with mild shortness of breath and mild generalized fatigue without any aggravating or relieving factors. The patient denied loss of consciousness, presyncope or palpitations. The patient trialed of proton pump inhibitor for 5 days without relief and denied any recent vaccination, recent upper respiratory tract infection or known sick contacts. He was a nonsmoker, denying alcohol or illicit substance use and no known family history of premature coronary artery disease or autoimmune disorders. He was normotensive with regular rate. His physical examination was normal without rub or murmur. Labs showed a leukocytosis of 11.6 k/uL with neutrophilic predominance. Cardiac profile showed significantly elevated high-sensitivity cardiac troponin (hs-cTn) of 1066 ng/mL and elevated total CK of 670 U/L. CRP was elevated as well. Troponin levels continued to rise in setting of normal renal function. EKG showed nonspecific ST elevations in lead I and II not sufficient in amplitude for diagnosis. Echocardiogram showed ejection fraction of 50-55% and CTA chest showed the heart size to be at upper limit of normal for the patient’s age, otherwise non-significant. A cardiac MRI was done which showed late gadolinium enhancement involving the mid myocardium to epicardium, sparing the endocardium and involving the basal inferior and inferolateral walls consistent with acute myocarditis. No evidence of pericarditis found on cardiac MRI. Patient remained stable in hospital. Subsequently, he was diagnosed with acute myocarditis. Further evaluation for myocarditis etiology yielded a negative respiratory viral panel, elevated Mycoplasma pneumoniae Ig G with negative Ig M, elevated HSV1 Ig G, and parvovirus antibodies within normal limits. Coxackie A serotype titer was 1:16, in indeterminate range. Our patient was discharged home on colchicine for one month and recommended outpatient follow up.
Discussion: Myocarditis can present with nonspecific symptoms as well as chest pain, arrythmias, new onset heart failure or sudden cardiac death [1]. Physical examination findings can be non-specific, as in our patient. Often myocarditis is suspected when there are elevated cardiac biomarkers, ECG changes suggestive of myocardial injury and global or regional abnormalities of LV systolic function on echocardiography.[2] Coronary angiography is indicated in selective cases with suspicion of ACS. Cardiac MRI is indicated with elevated troponin and/or ventricular dysfunction without a clear etiology. An EMB is performed only if likelihood of EMB is to significantly affect management.[3] Treatment is usually directed towards the presenting symptoms or complications from myocarditis such as cardiomyopathy or arrythmias. [4] The specific etiology of myocarditis, if known, should be addressed as well. Although most patients have partial or full recovery, in some patients the process can continue sub-clinically with symptoms recurring. Clinical follow-up is necessary for patients with myocarditis and possible reassessment with echocardiogram due to risk of dilated cardiomyopathy. Return to physical activity may be permitted gradually with monitoring of symptoms. [5]
