Acute Myocarditis Presenting as Cardiac Tamponade
Myocarditis refers to an inflammatory disease of the myocardium. The process may be focal or diffuse and is associated with cardiac dysfunction. Myocarditis may exist with or without pericardial involvement.
The etiology of myocarditis includes infectious and noninfectious agents. Viral agents are responsible for most cases of myocarditis in the United States. Overall, the enteroviruses are the most common cause of viral myocarditis. These include Coxsackie A, Coxsackie B, Polio, and Echoviruses, with Coxsackie В virus predominating. Other viruses include Influenza A and B, Epstein-Barr virus, Adenovirus and Cytomegalovirus.
REPORT OF CASE
A 53-year-old Hispanic woman with no past history of cardiac disease presented to the emergency room with a six-day history of “cold”, malaise, generalized weakness, nausea, and body aches. On examination, she was pale with cold clammy extremities. Her pulse was 114/min and blood pressure 75/50 mmHg. She had no jugular venous distension (JVD), heart sounds were normal with no added sounds, and her lungs were clear to auscultation. The rest of the initial physical assessment was unremarkable.
Laboratory data revealed elevated cardiac enzymes with mild leucocytosis. She had a widened mediastinum with no pulmonary infiltrates on chest radiograph. An electrocardiogram (EKG) showed sinus tachycardia, low voltage complexes and widespread ST-segment elevation. An emergency transesophageal echocardiogram (TEE) was performed in order to exclude aortic dissection. It revealed a markedly reduced left ventricular systolic function, concentric left ventricular hypertrophy, moderate pericardial effusion with tamponade, and no evidence for aortic dissection (Figure 1). Since the pericardial effusion was predominantly posterior in location she was referred for a pericardial window, because pericardiocentesis was considered not to be technically feasible. Approximately 400 cc of straw, colored fluid was initially drained from the pericardial space at surgery.
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Figure 1. TEE showing short axis view of right and left ventricles. There is pericardial effusion (predominanfly posterior in location) compressing the right ventricle. See arrows.
Postoperatively, she was hypotensive and tachy-cardic. A Swan-Ganz catheter was placed with initial readings consistent with cardiogenic shock. She was treated with dobutamine and dopamine. Subsequent laboratory data revealed elevated titers of Influenza B. Considering her flu-like symptoms on presentation, the elevated cardiac enzymes (creatinine kinase MB fraction) and serology results, a clinical impression of acute myocarditis secondary to Influenza В virus, complicated by pericardial involvement, was made. Repeat echocardiogram showed no pericardial effusion, moderately reduced systolic function and regional wall motion abnormalities. Following significant improvements in the hemodynamic parameters, dopamine was tapered off with introduction of oral digoxin and enalapril. The later was substituted with isordil and hydralazine when she developed cough. The remainder of her hospital stay was remarkable for nosocomial pneumonia with right pleural effusion. She made clinical progress and follow-up echocardiogram after two weeks of therapy showed normal left ventricular dimension, normal global and regional systolic function without pericardial effusion, and she was subsequently discharged. About two months after discharge, transthoracic echocardiogram and chest radiograph were normal, and she had no symptoms of heart failure. buy tadacip