16 Jan 2021

12/14/20: Fulminant Myocarditis 2/2 Influenza

PGY2 Sophie Miller presented a case of a 51 year old F with no significant medical history who presents with to the ED with worsening chest pain and confusion.  Patient was initially found confused, with fevers and chills, breathing rapidly and diaphoretic 1 week prior and was brought to the ED at that time and was deemed stable for discharge home with Levaquin 500mg x7 days.  Two days prior, she noticed mid-sternal chest heaviness that radiated to the head, was unchanged with exertion and associated with SOB at rest.  No syncope, dizziness, palpitations or edema.  She was seen in the ED again, thought pain was related to pneumonia and no further interventions done.  Her chest pain has been getting progressively worse, but unchanged in character.  No focal weakness, sensation loss.  No vision changes, HA, n/v.  Can typically walk without limitations, denies overt orthopnea or LE edema.  No sick contacts or recent travels.  ROS significant for sore throat, dry cough and night sweats.

Vitals: T 37.4, HR 140-160, RR 27, BP 71/41, O2 sat 97% on 15L NRB -> BIPAP

Physical Exam significant for ill appearing, lethargic female, tachycardic, tachypneic with crackles throughout; skin cool and dry; no edema bilaterally; initially unable to assess due to altered mental status, after stabilizing interventions, improved to A&Ox4

CBC: WBC 15.8> Hb 14.9/Hct 44.7 <Plt 167 (MCV 88.2, RDW 14.3%)

CMP:

Na 137/K 4.2/Cl 100/HCO3 19/BUN 14/Cr 0.86<Glucose 145

ALP 69>T.protein 5.9/Albumin 3.6/AST 72/ALT 33/Tbili 0.3

Ca 9.1, Mg 1.9, Phos 2.8

Coags: PT 16, INR 1.3

Infectious workup initiated, with the following findings:

  • BCx, UA negative; Sputum culture with 1+ normal flora isolated in normal numbers
  • Lactate elevated at 6.4, procal 0.06
  • SARS-CoV-2, HIV and RPR not detected
  • Influenza A positive, Influenza B and RSV negative
  • CXR on 2 days prior to presentation (L) and admission (R)

Cardiology workup:

  • ABG: 7.38/25/191/15, 36% FiO2
  • Trop neg 0.72 -> 0.99
  • Pro-BNP 13563 (normal <125)
  • TSH: 1.83 (normal: 0.27 – 4.2)
  • HbA1c 5.8%
  • Lipid panel: Chol 156, HDL 29, LDL 64, TG 314
  • EKG 1 week prior:
  • EKG 2 days prior:
  • EKG on presentation:
  • TTE done with EF 10%, severe diffuse hypokinesis

Right Heart Catheterization done showed no coronary artery disease, elevated R and L filling pressures, and cardiogenic shock.

Treatment: Patient was found to be in cardiogenic shock and she was started on levo/dobutamine.  The patient became tachycardic and hypoxic and started on bipap for respiratory support.  She was taken to the cath lab and given evidence of cardiogenic shock, IABP and impella were placed.  Given continued poor cardiac function and pressor dependence, patient was initiated on Solumedrol (2 day pulse) and IVIg (2mg over 5 days) for treatment of her fulminant myocarditis.  Patient eventually improved on hospital day 6 and was weaned off pressors and impella and IABP discontinued on hospital day 8.  Her repeat TTE demonstrated recovered myocardium with EF of 50% and she was discharged to acute rehab.

Teaching points:

  1. Consider myocarditis in patient with infection and EKG changes (low voltage).
  2. Fulminant myocarditis (FM) is life threatening and delay in diagnosis can result in significant morbidity and mortality.
  3. Management:
    1. Supportive cares
    1. Steroids – commonly given in lymphocytic FM, no clear evidence
    1. Giant cell/eosinophilic: steroids +/- cyclosporine
    1. IVIg – more commonly used in pediatric lymphocytic FM.  Not recommended by WHO given limited evidence

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