A 53-year-old female with a history of asthma since many years ago and coronavirus disease 2019 (COVID-19) infection two weeks ago was admitted with dyspnea, pleuritic chest pain, and scattered neuropathic pains since one week ago. The patient also had complaints of blurred vision since the time of the COVID-19 infection. Moreover, the patient mentioned a history of vitrectomy due to trauma. A family history of rheumatoid arthritis was positive in her brother.
On admission, blood pressure, pulse rate, oral temperature, and oxygen saturation were reported as 100/80 mmHg, 85 beats/minute, 36.7°C, and 94%, respectively. Electrocardiogram revealed sinus rhythm with the right bundle branch block (
Figure 1). She underwent transthoracic echocardiography (TTE) one week before admission, which reported a normal left ventricular size with left ventricular ejection fraction (LVEF) of about 50 - 55%. In our center, Modarres Hospital, TTE was repeated and demonstrated LVEF 20 - 25% with global hypokinesia, normal right ventricular size and function, and unremarkable valvular disease. A chest X-ray was unremarkable except for moderate size left-sided pleural effusion, which was confirmed by a chest computed tomography scan. The passive collapse of the lingula and left lower lobe was also reported.
Electrocardiogram showing sinus rhythm with right bundle branch block
Laboratory tests revealed a troponin I level of 1.44 ng/mL (normal < 0.03 ng/mL), urea level of 42 mg/dL, creatinine level of 0.8 mg/dL, aspartate aminotransferase level of 46 U/L, alanine aminotransferase level of 48 U/L, white blood cell count of 14.8 × 103/microliter, neutrophil level of 72%, a hemoglobin level of 11.4 g/dL, thyroid stimulating hormone level of 1.3 mIU/mL, and N-terminal pro-B-type natriuretic peptide level of 13100 pg/mL (normal level < 120 pg/mL). On the third day of admission, we asked for an eosinophil count, which was transiently 38% only in one sample.
Due to the rapid decrease in LVEF, dyspnea, and chest pain, acute coronary syndrome and acute myocarditis were two main differential diagnoses. In order to evaluate the coronary arteries, coronary angiography was performed, which revealed normal epicardial coronary arteries. Based on the initial diagnosis of acute myocarditis, the patient received two doses of intravenous methylprednisolone (500 and 250 mg), which was continued by oral prednisolone. Eosinophil count became normal after receiving prednisolone, and the troponin level started to decrease. The LVEF improved by 40%, and symptoms of heart failure were relieved after diuretic therapy and standard heart failure treatment.
The evaluation of the cause of myocarditis was continued, and an endomyocardial biopsy was performed, which reported evidence of inflammatory cell infiltration and necrosis but not specific to a special cause. Stool examination was negative for parasitic infection and mutations for
JAK2 and
PDGFR (to evaluate eosinophilia). Rheumatologic tests were also negative. Furthermore, the ophthalmologic study was unremarkable. Finally, the patient was diagnosed with EM based on the presence of subendocardial edema and late gadolinium enhancement in cardiac MRI (
Figure 2). Oral prednisolone, 15 mg per day, was continued after intravenous pulse concomitant with anti-heart failure medications (i.e., spironolactone, carvedilol, empagliflozin, and enalapril). During the follow-up period, LVEF improved to 50% after one month, and the case remained asymptomatic.
A and B, Short axis and four-chamber view of cine steady-state free precession sequence showing large pericardial effusion and pleural effusion; C, short axis dynamic perfusion sequence showing subendocardial perfusion deficit; and D, short axis late gadolinium enhancement sequence showing subendocardial hyperenhancement