Author + information
- Ye Zi,
- Huang Ying-xiong,
- Jiang Peng,
- Zheng Zi-yu and
- Zhan Hong
Fulminant myocarditis(FM) is a rare life threatening disease and common to make misdiagnosis, particularly in elderly patients. To investigate the characteristic, diagnostic and therapeutic method of FM.
The clinical data of one elderly patient with FM were collected and relevant literature were reviewed.
A 61-year-old male patient was brought to emergency department (ED) with nausea, vomiting and palpitation for 10 hours. His past medical history was unremarkable. A general physical examination has no obvious abnormity. On admission, BP was 121/98mmHg and HR was 121 bpm. ECG showed sinus tachycardia and ST-segment slight depression less than 0.05mv over V3-V6. The results of determination showed: WBC: 24.42×10ˆ9/L, PCT: 15.71ng/ml, Pro-BNP: 7678.0pg/ml, troponin T was 8.77ng/ml, and rose to 13.55ng/ml 4 hours later. Over the next 6 hours, he quickly decompensated and went into refractory cardiogenic shock and severe hypoxemia. The patient was intubated and ventilator support immediately. Bedside echocardiogram revealed global impairment of cardiac systolic function with a LVEF of 30%. The diagnosis of FM was highly suspected. Due to fear of complications and economic reasons, his families rejected endomyocardial biopsy (EMB) for more definitively diagnose and extracorporeal membrane oxygenation (ECMO). Hemodynamic support, antibiotic therapy, intravenous methylprednisolone (40mg/d) and immunoglobin therapy were administered. He was transferred to CCU for further treatment. His hemodynamics was gradually stabilizing and CAG was arranged on hospital day 8, which revealed 30% local stenosis of the distal LCA. He was discharged after 18 days. One months later, reexamination of echocardiogram revealed LVEF of 56%, Septa and LV wall thickness were increased.
It remains great challenging for clinician to differentiate between FM and severe myocardial infarction, particularly in the elderly patients and at the early stage. EMB provides a definitive etiological diagnosis that can lead to specific treatments by using Dallas criteria. However, EMB seems to be not routinely used for multiple reasons in clinical. Cardiovascular magnetic resonance (CMR) is a valuable noninvasive imaging to diagnose myocarditis at early terms by using Lake Louise Criteria. However, it is limited in FM due to hemodynamically unstable. In the urgent period, echocardiography is most commonly used in suspected FM to exclude other causes of heart failure and for chamber quantification. We aim to emphasize the vital importance of experience with a high index of suspicion leading to early diagnosis. Clinical clues to FM include preceding the onset of symptoms (eg. gastrointestinal or respiratory infection), cardiac enzymes increase, elevated inflammatory markers, and new onset ongoing cardiogenic shock incorporating bedside echocardiogram findings. Treatment of FM remains largely supportive. Steroid and immunomodulating therapy for FM still has controversial according to the literatures.