Acute lymphocytic myocarditis

Myocarditis is an inflammatory disease of the myocardium. The clinical presentation of myocarditis may range from subclinical to sudden death. The incidence of fatal myocarditis, which often presents with sudden or rapid death, has been estimated at 0.15/100.000 in the general population and is highest in infants and young adults (but may affect any age group). However, diffuse myocarditis in autopsies of sudden death is < 2% in adult. Myocarditis usually presents with heart failure symptoms over a few days to weeks. The classic presentation of viral myocarditis includes a viral prodrome with fever, myalgia, and upper respiratory symptoms. Patients present with dyspnea, chest pain, and arrhythmias. ECG abnormalities are often present, along with evidence of myocardial damage with elevated troponin levels. We present the case of a 78 year old white male who died from acute cardiac decompensation from diffuse acute lymphocytic myocarditis. A 78 year old white male with a medical history of hypertension and asbestosis who presented to the emergency department with agitation and wide complex tachycardia after three nights of difficulty sleeping, shortness of breath and diaphoresis. Patient required emergent intubation for hypoxic respiratory failure. An ECG performed at the time of admission was read as possible STEMI and the patient was taken to the cardiac catheterization lab. The procedure found open and patent coronary vasculature within the exception of occlusion of a branch of the second obtuse marginal artery branching from the left circumflex artery which was treated with a Plain Old Balloon Angioplasty (POBA). During the same day, patient went into cardiac arrest and deceased. An autopsy, the major pathological findings that explain the patient’s terminal course were in the heart which was affected by extensive diffuse myocarditis, predominantly lymphocytic with associated myocyte necrosis and dilated cardiomyopathy. The inflammation is more marked in the left than the right ventricle and is also involving the papillary muscles, endocardium and focally the epicardium. Scarring with dystrophic calcification in addition to the inflammation is present at the atrioventricular-septal junction (AV node site). Inflammation is also focally present at the junction of right atrium and superior vena cava (SA node site). Myocardial scar tissue from remote infarction or chronic ischemia is present in the inner lateral wall of the left ventricle. In this case, the predominance of lymphocytic infiltrate in myocarditis without neutrophil microabscesses, prominent eosinophils, giant cells or granuloma is most consistent with the differential etiology of viral/postviral infection, autoimmune/connective tissue disease or idiopathic.