Difficulties in myocarditis diagnosis: a case report

Cover Image

Cite item

Full Text

Abstract

Myocarditis is often difficult to diagnose. The diagnostic difficulties include nonspecific symptoms or a “vague” clinical picture, absence of pathognomonic signs during physical examination, and endomyocardial biopsy, which is the “gold standard” of diagnosis of myocarditis, being an invasive procedure that is performed under strict indications in certain patients. Nevertheless, as radiology is rapidly developing, clinicians are now able to noninvasively diagnose symptoms of inflammatory myocardial damage, including edema and myocardial fibrosis, using cardiac magnetic resonance imaging. This article presents the clinical case of a young patient with symptoms of acute coronary syndrome, who showed no evidence of coronary artery disease. Myocarditis was suspected because of increased activity of cardiospecific enzymes and high levels of inflammatory markers, pronounced electrocardiography changes with positive dynamics, and recent infection. Magnetic resonance imaging was used to confirm myocarditis diagnosis. Thus, this case study demonstrates the role of imaging techniques in the differential diagnosis of ischemic and inflammatory heart diseases.

About the authors

Natalia G. Poteshkina

The Russian National Research Medical University named after N.I. Pirogov; Moscow City Hospital 52

Author for correspondence.
Email: nat-pa@yandex.ru
ORCID iD: 0000-0001-9803-2139
SPIN-code: 2863-4840

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow; Moscow

Elena A. Kovalevskaya

The Russian National Research Medical University named after N.I. Pirogov; Moscow City Hospital 52

Email: tolyaaa@mail.ru
ORCID iD: 0000-0002-0787-4347
SPIN-code: 8853-2700

MD, Cand. Sci. (Med.), Assistant professor

Russian Federation, Moscow; Moscow

Valentin E. Sinitsyn

Lomonosov Moscow State University Medical Research and Educational Center

Email: vsini@mail.ru
ORCID iD: 0000-0002-5649-2193
SPIN-code: 8449-6590

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Elena A. Mershina

Lomonosov Moscow State University Medical Research and Educational Center

Email: elena_mershina@mail.ru
ORCID iD: 0000-0002-1266-4926
SPIN-code: 6897-9641

MD, Cand. Sci. (Med.), Assistant professor

Russian Federation, Moscow

Daria A. Filatova

Lomonosov Moscow State University Medical Research and Educational Center

Email: dariafilatova.msu@mail.ru
ORCID iD: 0000-0002-0894-1994
SPIN-code: 2665-5973
Russian Federation, Moscow

Galina B. Selivanova

The Russian National Research Medical University named after N.I. Pirogov

Email: galina.selivanova@rambler.ru
ORCID iD: 0000-0003-2980-9754
SPIN-code: 9711-5041

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Yavilika R. Shashkina

Moscow City Hospital 52

Email: yavilika-medik@mail.ru
ORCID iD: 0000-0002-2194-0785
Russian Federation, Moscow

References

  1. Ammirati E, Moslehi JJ. Diagnosis and Treatment of Acute Myocarditis: A Review. JAMA. 2023;329(13):1098–1113. doi: 10.1001/jama.2023.3371
  2. Caforio ALP, Calabrese F, Angelini A, et al. A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. European Heart Journal. 2007;28(11):1326–1333. doi: 10.1093/eurheartj/ehm076
  3. Leone O, Veinot JP, Angelini A, et al. 2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovascular Pathology. 2012:21(4):245–274. doi: 10.1016/j.carpath.2011.10.001
  4. Arutyunov GB, Paleev FN, Moiseeva OM, et al. 2020 Clinical practice guidelines for Myocarditis in adults. Russian Journal of Cardiology. 2021;26(11):4790. (In Russ) doi: 10.15829/1560-4071-2021-4790
  5. Schultz JC, Hilliard AA, Cooper LT, et al. Diagnosis and Treatment of Viral Myocarditis. Mayo Clinic Proceedings. 2009;84(11):1001–1009. doi: 10.1016/s0025-6196(11)60670-8
  6. Caforio ALP, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European Heart Journal. 2013;34(33):2636–2648. doi: 10.1093/eurheartj/eht210
  7. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper. Journal of the American College of Cardiology. 2009;53(17):1475–1487. doi: 10.1016/j.jacc.2009.02.007
  8. Tijmes FS, Thavendiranathan P, Udell JA, et al. Cardiac MRI Assessment of Nonischemic Myocardial Inflammation: State of the Art Review and Update on Myocarditis Associated with COVID-19 Vaccination. Radiology: Cardiothoracic Imaging. 2021;3(6):e210252. doi: 10.1148/ryct.210252
  9. Srichai MB, Lim RP, Lath N, et al. Diagnostic performance of dark-blood T2-weighted CMR for evaluation of acute myocardial injury. Investigative Radiology. 2013;48(1):24–31. doi: 10.1097/rli.0b013e3182718672
  10. Galán-Arriola C, Lobo M, Vílchez-Tschischke JP, et al. Serial Magnetic Resonance Imaging to Identify Early Stages of Anthracycline-Induced Cardiotoxicity. Journal of the American College of Cardiology. 2019;73(7):779–791. doi: 10.1016/j.jacc.2018.11.046
  11. Blagova OV, Pavlenko EV, Varionchik NV, et al. Myocarditis as a legitimate phenomenon in patients with primary noncompaction myocardium: diagnosis, treatment and impact on outcomes. Russian Journal of Cardiology. 2018;23(2):44–52. (In Russ) doi: 10.15829/1560-4071-2018-2-44-52
  12. Filatova DA, Mershina EA, Sinitsyn VE. COVID-19-related cardiac lesion: The questions of pathogenesis and diagnostics. Digital Diagnostics. 2023;4(2):156−169. (In Russ) doi: 10.17816/DD284706

Supplementary files

Supplementary Files
Action
1. JATS XML
Download
2. Fig. 1. Electrocardiography of patient M. at the prehospital stage.

Download (293KB)
Indexing metadata
3. Fig. 2. Coronary angiography of patient M.: a — left coronary artery; b — right coronary artery.

Download (164KB)
Indexing metadata
4. Fig. 3. ECG of patient M. in dynamics.

Download (250KB)
Indexing metadata
5. Fig. 4. Magnetic resonance imaging of the heart in delayed contrast mode with a gadolinium-containing contrast agent (7–15 minutes after administration of the contrast agent), pulse sequence Flash 2D Inversion Recovery: a, d — short axis of the left ventricle in the basal segments; b, e — long axis of the left ventricle, four-chamber view; c, f — long axis of the left ventricle, two-chamber view. Top row, a–c — magnetic resonance imaging of the heart initially: in the basal and middle lateral and inferior segments with a transition to the apical inferior segment of the left ventricle, subepicardial areas of contrast are noted (yellow arrows); bottom row, d–f — dynamic magnetic resonance imaging of the heart after 1.5 months: areas of delayed contrast of the previous localization and intensity remain.

Download (187KB)
Indexing metadata
6. Fig. 5. Magnetic resonance imaging of the heart in T2-mapping mode along the short axis of the left ventricle in the basal segments: a — magnetic resonance imaging of the heart initially: in the area of the lower and inferolateral segments there is an increase in the T2 relaxation time (>50 ms), which indicates presence of edema; b — magnetic resonance imaging of the heart in dynamics after 1.5 months: the native T2 parameter is within normal values (<50 ms). The numbers indicate the values of the T2 relaxation time in ms.

Download (193KB)
Indexing metadata

Copyright (c) 2023 Eco-Vector

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Согласие на обработку персональных данных

 

Используя сайт https://journals.rcsi.science, я (далее – «Пользователь» или «Субъект персональных данных») даю согласие на обработку персональных данных на этом сайте (текст Согласия) и на обработку персональных данных с помощью сервиса «Яндекс.Метрика» (текст Согласия).