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Hypersensitivity (Eosinophilic) Myocarditis - 11/27/2012

posted Nov 23, 2012, 2:11 PM by Monique Tanna   [ updated Dec 27, 2012, 6:40 AM by Purnema Madahar ]
This week we presented another great case to Dr. Mario Garcia, Chief of Cardiology.  The case was about a 31 year old male, college student, with a history of hypertension who initially presented to Nyack Hospital on 9/28/12 with 4 days of LLQ pain, diarrhea, and fever, and was found to have sepsis and imaging consistent with colitis.  He was treated with flagyl and levaquin, which were switched to Zosyn and eventually doripenem when pt developed a maculopapular rash on his chest thought to be due to Zosyn.  He had a flex sigmoidoscopy on 10/2 after which he developed hypotension, shock liver, AKI, and an LVEF of 20%.  He was intubated and started on vasopressin, levophed, and milrinone.  He had a CVP of 24, CPK 514, troponin 7.4, and was transferred to MMC due to concern for myocarditis and eval for possible LVAD or ECMO. 

Here, he had a RHC on 10/3 which revealed normal CI (2.5) with elevated filling pressures: RA 21, RV 36/20, PA 37/21, PCWP 22, PA sat 52%, AVO2 5.67, CO/CI 6.27/2.5, HR 115 while on vasopressin 0.08.  EKG showed an accelerated junctional rhythm at 208 bpm with IVCD, and subsequently atrial fibrillation.  Repeat TTE showed four chamber dilatation, severely decreased LVEF, severe RV hypokinesis, severe TR, moderate MR.  RHC biopsy revealed eosinophils concerning for allergic type/hypersensitivity myocarditis.  The pt was given supportive care, broad spectrum antibiotics (imipenem and doxycycline), a brief course of IVIG for possible toxic shock syndrome, SLED therapy and subsequently HD for AKI (thought to be due to shock/ATN).  The exact etiology of his deterioration remains unclear, but the pt was thought to have both septic and cardiogenic shock, either due to the infection/colitis itself, and/or from a hypersensitivity reaction to antibiotics.  He did well and repeat TTE on 10/27 showed complete recovery with an EF of 65%, normal chamber sizes, minimal MR and TR, and mild-moderate pulmonic insufficiency.  Renal function also recovered and pt did not continue requiring HD (creatinine returned to 1.0).  He was discharged to acute rehab on 11/13.

Attached is a Case Record from MGH published in the NEJM of a 31 year old woman with rash, fever
, and hypotension found to have eosinophilic myocarditis, and a similar discussion of the various etiologies of cardiomyopathy.  A review of acute LV dysfunction in the critically ill (an alternative diagnosis that was also entertained) is also attached.
Case Record of the Massachusetts General Hospital
Sabatine MS, Poh KK, Mega JL, Shepard JA, Stone JR, Frosch MP. Case records of the Massachusetts General Hospital. Case 36-2007. A 31-year-old woman with rash, fever, and hypotension. N Engl J Med. 2007 Nov 22;357(21):2167-78.

Acute LV Dysfunction in the Critically Ill
Chockalingam A, Mehra A, Dorairajan S, Dellsperger KC. Acute left ventricular dysfunction in the critically ill. Chest. 2010 Jul;138(1):198-207.