CARDIOLOGY CASE DISCUSSIONCARDIOLOGY CASE DISCUSSION

VICTOR TSENG, MDANDREW MCCUE, M4

NOVEMBER 22, 2013

A 35-Year-Old Man with A 35-Year-Old Man with DyspneaDyspnea

Chief Complaint/HPI

35 YEAR OLD MAN

COUGH, CORYZA, FEVERstarted 9/5/2013 minimal pinkish sputum, slowly progressive, mild wheeze, no chest painhome T 39◦C with occasional rigors ROS: (-) pharyngitis, (-) adenopathy, (-) reflux, (-) sinus congestion, (+) rhinoconjunctivitis, (+) malaise, (+) myalgias

DYSPNEAbecame noticeable on 10/15/2013 new 4-pillow orthopnea, + PND, slight pedal edema to thighs, now chairbound with SOBROS: (-) palpitations, (-) pleurisy, (-) presyncope, (-) unilateral calf swelling

MEDICAL HISTORY

Ph+ ALL (August 2012) s/p URD PB SCT (May 2013) good engraftment molecular remission

Grade 2 GVHD Colitis and Dermatitis

E. faecalis bacteremia and severe sepsis (Feb 2013)

SOCIAL HISTORY

Born in India, immigrated to U.S in 2010 Software engineer for Coca Cola™ Never smoker, never EtOH, no recreational/illicit drug use No environmental allergies Never homeless, incarcerated, communal habitation Married and monogamous Has 5 y/o son who was recently ill with upper-respiratory

symptoms

MEDICATIONS

acyclovir 400 mg, PO, q12hr

albuterol 90 mcg/inh MDI QID, PRN

benzonatate 100 mg, PO, TID, PRN

dasatinib 40 mg, PO, qDay

lorazepam 0.5 mg, PO, q6hr, PRN

oxycodone 10 mg, PO, q4hr, PRN

pentamidine Inhale, qMonth

VITAL SIGNS

T 36.4

BP 85/40

HR 160 (regular)

RR 32

SpO2 100%

WT 152 lbs

HT 67 inches

PHYSICAL EXAM

GEN: diaphoretic, severe distress HEENT: sclera with suffusion, posterior pharynx with erythema, oral

mucosa moist, no thyromegaly or bruit, no sinus tenderness NEURO: AO x 4, normal sensorium, no lateralizing motor or sensory

deficits COR: very rapid regular, summation gallop, no rubs, nondisplaced apical

impulse VASCULAR:

v: engorged IJV,+ HJR, + Kussmaul’s a: pulsus pressure = 20, pulsus alternans (2+/1+), warm extremities

RESPIRATORY: speaking in clipped sentences, clear lung fields, good air entry

ABDOMEN: soft, flat, non-tender, non-distended, MSK: normal ROM, no joint effusions SKIN: no rashes LYMPH: no cervical adenopathy

LABORATORY DATA (PART 1)

135

4.3

100

25

17

0.7164 16.0

13.5

40.5161

9.42.0

5.6 2.9

0.9

438 172

104

Tn-I/CK-MB Pending

CXR

CT Chest

CORONARY ANGIOGRAPHY (LHC)

RAO Left System LAO Right System

ECHOCARDIOGRAM (TTE) I

ECHOCARDIOGRAM (TTE) II

LABORATORY DATA (PART 2)

PCR (Nasopharyngeal Swab)

AdenoV NEG

RSV-A/B POS (A)

PIV (1 – 3) NEG

Influenza A/B NEG

MPnV NEG

RhinoV NEG

Serology (Peripheral Blood)

EchoV NEG

EnteroV NEG

EBV NEG

HSV -1/2 NEG

HTLV – 1/2 NEG

PCR (Peripheral Blood)

AdenoV NEG

CoxV-A/B1 – B6

NEG

EnteroV NEG

CMB NEG

HIV NEG

Troponin-I 30.22

ESR 17

CRP 22.8

BNP 73

HEMODYNAMICS

18 (≤8)

20/11 (25/5)

11 (≤12)

PA SpO2 = 58%

Art SpO2 = 99%

CO (Fick) = 3.4 LPM

SIDE NOTE

CO = HR × SV

“Sometimes, the scariest rhythm in the CCU is bad sinus

tacycardia”Robert Cole, MDHF/CCU Attending

HISTOPATHOLOGY I

HISTOPATHOLOGY II

DIAGNOSIS

DIAGNOSISFulminant Lymphocytic MyocarditisRSV Bronchiolitis

COMPLICATIONSCardiogenic ShockAcute RV FailureVentricular Tachycardia Storm

HOSPITAL COURSE

Transferred to CCU Swan-Ganz (PA) Catheter for tailored IVF and inotrope

therapy High-dose IV Steroids x 3d then PO taper ST elevations resolved by day 4, Tn-I peaked at 34.7 ng/mL Shock/Tachycardia resolved by 1 week Ribavirin + Palivizumab (Synagis™), aggressive pulmonary

toilet LifeVest for protection of VT RVEF with recovery to normal by 2 weeks Good rehabilitation and discharged home Doing well

FRANK CORRIGAN III, MD

MYOCARDITIS

Inflammatory Cardiomyopathy

Myocarditis w/ Myocardial DysfunctionMost Common Etiologies: Parvo B19, HHV 6 Findings predictive of subsequent death or

transplantation Syncope (RR 8.5), bundle branch block (RR 2.9), LVEF

<40% (RR 2.9)

Secondary pHTN (mean PAP) most predictive of death. Each 5mmHg increase from baseline MPAP, mortality

increased with Hazard Ratio 1.85 (HR 1.23 in those without myocarditis)

Classification

Giant Cell etiology unknown. Most severe symptoms. Mediated

by T cells and giant cells

Fulminant Most commonly a viral etiology p/w with acute HF up to 2 weeks after distinct viral

prodrome.

Acute p/w less distinct symptom onset. Have established

ventricular systolic dysfunction.

Outcomes

Patients with fulminant myocarditis, although more severely ill, are more likely to recover than those with acute myocarditis.

At 11 year follow-up, transplant-free survival was 93% fulminant vs. 45% acute.

Giant Cell Myocarditis: rate of death or cardiac transplant 89%. Median survival from symptom onset 5.5 months

Who to Biopsy?

New onset HF of ≤ 2 weeks duration associated with a normal LV chamber size and hemodynamic compromise

New onset HF of 2 weeks – 3 months duration associated with a dilated LV

New ventricular arrhythmias2nd or 3rd degree AV blockFailure to respond to usual care within 1-2

weeks

EMB vs. Cardiac MR

CMR shows most common site of focal involvement was epicardial surface of LV free wall.

Study showed EMB + myocarditis in 19/21 patients directed by CMR imaging (suggestive of myocarditis)

*Most EMBs obtained from RV side of IVS

Dallas Criteria

Active myocarditis- an inflammatory infiltrate of the myocardium with necrosis &/or degeneration of adjacent myocytes not typical of ischemic damage associated with CAD

Borderline myocarditis- the inflammatory infiltrate is too sparse or myocyte injury is not demonstated

References

Cooper, LT Jr. 2009. Myocarditis. NEJM 360(15):1526 Goldberg, LR, Suk, J, et at. 1999. Predictors of adverse outcome of biopsy-proven

myocarditis. J Am Coll Cardiology. 33:A850. McCarthy RE, Boehmer JP, et al. 2000. Long-term outcome of fulminant myocarditis as

compared to acute. NEJM 342(10):690 Mahgholdt H, Goedecke C, et al. 2004. Cardiovascular magnetic resonance assessment

of human myocarditis. Circulation. 109(10):1250. Aretz HT, Billingham ME, et al. 1987. Myocarditis: a histopathologic definition and

classification. Am J Cardiovasc Pathol. 1(1):3.