Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Perimyocarditis describes inflammation of the pericardium and myocardium. Most cases are idiopathic, however when infectious causes are present, it is typically due to a virus such as coxsackievirus, adenovirus, herpesvirus, or echovirus amongst others. Clinical features vary from mild, self-limiting symptoms to cardiogenic shock and death. We will discuss a unique case of viral perimyocarditis presenting with hemoptysis, respiratory failure, and new-onset heart failure with severely reduced ejection fraction. A 59-year-old female with a history of asthma, hypertension, and recently treated pneumonia presented with acute-onset headache, fatigue, and shortness of breath. On admission, she was severely hypertensive in the 200s/90s. Associated symptoms included diffuse numbness, tingling, and weakness. Leukocytes were mildly elevated to 14.9 with other labs and physical exam unremarkable. EKG showed sinus bradycardia without evidence of acute ST changes. The patient’s headache was treated with Benadryl and Reglan, after which she began vomiting and became hypoxic to 60% and tachycardic to the 120s. She developed gross hemoptysis with frothy bloody sputum and required oxygen supplementation via high-flow nasal cannula (HFNC). CT angiography with IV contrast showed diffuse ground-glass airspace opacities concerning for infectious or inflammatory pneumonitis but no obvious aberrant vasculature. She was transferred to our hospital for higher levels of critical care. Initial examination was significant for tachycardia and tachypnea with physical exam notable for hemoptysis and bilateral wheezing. While on heated HFNC, oxygen saturations remained in the low 80s ultimately leading to intubation. Labs were remarkable for high-sensitivity troponin elevated at 2234 (peaked to >6000), elevated ESR and CRP, and arterial blood gas showing respiratory acidosis, hypoxia, and hypercarbia. Respiratory PCR and cultures, urine Legionella, Strep antigen, TB screen, and MRSA nares were all negative. Transthoracic echocardiography showed reduced ejection fraction at 10%, severe global hypokinesis, mildly decreased right ventricular systolic function, mild mitral and tricuspid regurgitation, and no pericardial effusion. She was started on Lasix 40mg BID, low dose carvedilol, and ACE inhibitor. Cardiac catheterization to rule out acute coronary syndrome in the setting of new-onset ST elevation in lead V2 showed non-ischemic cardiomyopathy with normal coronaries and low-normal filling pressures. A repeat echocardiogram days later showed an improved ejection fraction of 40%. Cardiac MRI revealed acute edema in the mid to apical and septal walls with hypokinesis and trivial pericardial effusion consistent with myocarditis. She continued having episodes of chest pain at night concerning for pericarditis and was started on colchicine and aspirin which relieved her pain. Coxsackie B Antibody Type 4 titers came back positive at 1:320 after discharge. Coxsackievirus infections usually have a milder disease course in adults, however in cases of pericarditis or myocarditis, severity can range from asymptomatic to fulminant heart failure as seen in this patient. This was a unique presentation with hemoptysis and respiratory failure which highlights how severe some of these cases can potentially get. Although it is a self-limited illness, it is important to consider viral perimyocarditis in differential diagnoses of hemoptysis and respiratory failure, especially in patients with a history of recent illness.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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