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

Priyanka Ghosh, DO; Saurabh Sharma, MD

Disclosures

June 01, 2022

The identification of the underlying cause of myocarditis helps direct management. Treatment is multifold and involves:

  • Management of the underlying etiology

  • Acute therapy, usually with corticosteroids

  • Treatment of concomitant heart failure or cardiomyopathy with guideline-directed medical therapy, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and/or sodium-glucose cotransporter 2 (SGLT2) inhibitors

  • Anticoagulation, if cardiac thrombus is detected, as in this patient

If hypersensitivity is suspected, prompt withdrawal of the offending agent should be considered. Although immunosuppressive therapy remains controversial and no large randomized controlled trial has examined outcomes, many case reports have shown success using intravenous methylprednisolone followed by oral prednisone.[6] The addition of azathioprine was effective in a patient who presented with cardiogenic shock from eosinophilic myocarditis.[7,8]

Because this patient experience clinical decompensation during his hospital stay, intravenous corticosteroid therapy (methylprednisolone 125 mg/d) was urgently initiated, and his symptoms improved. He also received guideline-directed medical therapy for his nonischemic cardiomyopathy and anticoagulation for the LV thrombus. He was transferred to a higher level of care for appropriate management of his acute leukemia and eosinophilic myocarditis.

In conclusion, eosinophilic myocarditis is a rare disorder. An elevated eosinophil count and cardiac-specific symptoms should heighten clinical suspicion for the disorder. Evidence of myocarditis and eosinophilic infiltration of the myocardium, which is obtained through invasive biopsy or cardiac MRI, establishes the diagnosis. Complications include restrictive cardiomyopathy, progression to cardiogenic shock, ventricular thrombus, pulmonary or systemic embolus, and mitral or aortic valve regurgitation. Treatment should be prompt and aimed at the underlying etiology. Corticosteroids have been shown to be beneficial; however, optimal management is complex owing to a lack of evidence-based guidelines.

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