Cardio Case Challenge: A Confused 35-Year-Old With Headache, Fever, and Sore Chest

Priyanka Ghosh, DO; Saurabh Sharma, MD

Disclosures

June 01, 2022

Physical Examination and Workup

In the emergency department, the patient's temperature is 100.5 °F (38.1 °C), heart rate is 85 beats/min, blood pressure is 103/82 mm Hg, respiration rate is 18 breaths/min, and oxygen saturation is 96% on ambient air. Upon physical examination, he appears ill but is not in acute distress. No nuchal rigidity is noted. Mucous membranes are moist. Results of a neurologic examination are normal.

A cardiac examination reveals a normal heart rate and rhythm, without murmurs, gallops, or rub. Palpation of the chest wall does not reproduce the chest discomfort. His lungs are clear to auscultation. An abdominal examination is benign and unremarkable. His peripheral extremities are warm and well-perfused and show no edema.

A complete blood cell count with differential reveals these values:

  • White blood cell (WBC) count: 55,450 cells/µL (reference range, 4230-9070 cells/µL)

  • Hemoglobin level: 15.7 g/dL (reference range, 13.7-17.5 g/dL)

  • Platelet count: 102,000 cells/µL (reference range, 163,000-337,000 cells/µL)

  • Neutrophils: 36.5% (reference range, 38%-70%)

  • Bands: 7% (reference range, 0%-8%)

  • Lymphocytes: 15.5% (reference range, 21%-49%)

  • Atypical lymphocytes: 9% (reference range, 0%-2%)

  • Monocytes: 1.5% (reference range, 1%-11%)

  • Eosinophils: 30% (reference range, 0%-7%)

  • Basophils: 0.5% (reference range, 0%-2%)

  • Absolute neutrophil count: 24,120 cells/µL (reference range, 1800-7700 cells/µL)

  • Absolute lymphocyte count: 8590 cells/µL (reference range, 1000-5000 cells/µL)

  • Absolute atypical lymphocyte count: 4990 cells/µL (reference range, 0-200 cells/µL)

  • Absolute monocyte count: 830 cells/µL (reference range, 0-800 cells/µL)

  • Absolute eosinophil count: 16,640 cells/µL (reference range, 0-500 cells/µL)

  • Absolute basophil count: 280 cells/µL (reference range, 0-200 cells/µL)

The results of a comprehensive metabolic panel are as follows:

  • Sodium: 132 mmol/L (reference range, 134-145 mmol/L)

  • Potassium: 4.3 mmol/L (reference range, 3.5-5.1 mmol/L)

  • Creatinine: 1.2 mg/dL (reference range, 0.8-1.5 mg/dL)

  • Blood urea nitrogen: 12 mg/dL (reference range, 9-20 mg/dL)

  • Aspartate aminotransferase: 75 U/L (reference range, 17-59 U/L)

  • Alanine aminotransferase: 38 U/L (reference range, 21-72 U/L)

  • Alkaline phosphatase: 50 U/L (reference range, 40-150 U/L)

The troponin level is elevated at 7.270 ng/mL (reference range, 0-0.034 ng/mL) and increases 3 hours later to 8.7 ng/mL, reaching a peak of 18.2 ng/mL. The erythrocyte sedimentation rate (ESR) is 20 mm/h (reference range, 0-15 mm/h). The C-reactive protein level is 19.60 mg/dL (reference range, < 1.00 mg/dL).

CT of the head without contrast shows no acute intracranial abnormality. CT of the chest with intravenous contrast reveals suspected splenomegaly in the visualized portion. ECG shows normal sinus rhythm with ST-segment depression in leads II, aVF, and V3-V6 (Figure 1).

Figure 1. ECG showing normal sinus rhythm with ST-segment depression.

The initial transthoracic echocardiogram (TTE) demonstrates normal left ventricular (LV) size and normal wall thickness (Figure 2). The estimated left ventricular ejection fraction (LVEF) is 55%-60%, right-heart size and systolic function are normal, and no hemodynamically significant valvular disease is detected.

Figure 2. Initial transthoracic echocardiogram demonstrating normal left ventricular size and a normal wall thickness.

Given the patient's chest discomfort, ECG abnormalities, and elevated troponin levels, coronary angiography is performed and reveals normal coronary anatomy, with no evidence of coronary disease (Figures 3 and 4). A repeat TTE on the third day of hospitalization demonstrates abnormal layered echo density in the LV apex (Figure 5).

Figure 3. Coronary angiogram showing normal coronary anatomy.

Figure 4. Coronary angiogram showing normal coronary anatomy.

Figure 5. Repeat transthoracic echocardiogram on the third day of hospitalization, demonstrating abnormal layered echo density in the left ventricular apex.

Cardiac MRI shows normal LV chamber size and normal contraction (Figure 6). The ejection fraction is 58%. Right ventricular size and function are normal. Tissue characterization shows a large area of subendocardial and mid-myocardial delayed enhancement that is most prominent in the LV apex, a laminated LV apical thrombus, and trivial circumferential pericardial effusion with evidence of diffuse pericardial inflammation.

Figure 6. Cardiac MRI showing normal left ventricular chamber size and normal contraction.

Because of the patient's neutrophilia, eosinophilia, moderate lymphocytosis, and thrombocytopenia, a bone marrow biopsy is ordered. The biopsy reveals 46% blasts and immunophenotypic findings that raise suspicion for acute leukemia with eosinophilia.

The results of an infectious disease workup are as follows:

  • Epstein-Barr virus (EBV) IgG antibodies: Positive

  • EBV IgM antibodies: Negative

  • Cytomegalovirus (CMV) IgG antibodies: Positive

  • CMV IgM antibodies: Negative

  • Mononucleosis screening test: Negative

  • Coxsackievirus antibodies: Negative

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