a case report of myocarditis and sinus arrest · a case report of myocarditis and sinus arrest...

Journal of Heart and Cardiology

J Heart Cardiol | Volume 2: Issue 1

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Introduction

Myocarditis isa focalordiffuse inflammatorydiseaseof themyocardium[1].Prevalenceofarrhythmiaassociatedwithmyocarditishasbeenreportedasmerely18%.Thesearrhythmiasincludenew-onsetatrialorventriculararrhythmiasorhigh-gradeAtrioventricular(AV)blockwhilesomeofthesearrhythmiasmaybelife-threatening[2].SeveralcasesofAVblockduringmyocar-ditiscoursehavebeenreported[3,4].Sinusarrhythmiasinmyocarditisareuncommon.Onlyonecaseofrecurrentsinusarrestlastingfor8secondsinapatientwithLymecarditishadbeenreported[5].Here,wereportacaseofacutemyocarditispresentingwithsyncoperelatedwithrecurrentsinusarrest.

Case Report A33-years-oldfemalepatientwasreferredtoourclinicforfurtherinvestigationofhersyncope.Thepatientdescribedfeverandflu-likesymptomsforthelast3days.Herphysicalexaminationwasnormal,withbloodpressure120/80mmHg,heartrate52bpmandbodytemperature37.1°C.Chest-Xraywasnormal.Electrocardiogram(ECG)revealedabnormalintraventricularconduction,firstdegreeAVblockandinvertedTwavesinleadsI,II,III,aVFandV3-6(Figure1A).Echocardiographicexamina-tionshowednormalleftventricularsystolicfunctionwithejectionfraction60%andmildpericardialeffusion.Herbloodtestsonadmissionwereasfollows;WhiteBloodCellcount(WBC)11.9110e3/µL(normalrange4.4-11.310e3/µL),haemoglobin12g/dL(normalrange11.7-16.1g/dL),plateletcount17510e3/µL(normalrange152-39610e3/µL),urea38mg/dL(normalrange16.6-48.5mg/dL),creatinine0.5mg/dL(normalrange0.5-0.9mg/dL),glucose83.5mg/dL(normalrange74-109mg/dL),sodium130

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DOI: 10.15436/2378-6914.16.024

Case Report Open Access

A Case Report of Myocarditis and Sinus Arrest

Filiz Kizilirmak Yılmaz*, Gultekin Gunhan Demir, Mehmet Onur Omaygenç, Bilal Boztosun

MedipolUniversityFacultyofMedicine,CardiologyDepartment,Istanbul,Turkey

*Corresponding author: FilizKizilirmakYılmazM.D.MedipolUniversityHospital,CardiologyDepartment,TEMAvrupaOtoyoluGöztepeÇıkışıNo:1,Bağcılar34214,Istanbul,TURKEY,Phone:(90)5055861728;Fax:(90)212-460-70-70;E-mail:filizkizilirmak@hotmail.com

Keywords: Myocarditis;Syncope;Sinusarrest

AbstractBackground:Myocarditisisafocalordiffuseinflammatorydiseaseofthemyocardium.Prevalenceofarrhythmiaassociatedwithmyocarditishasbeenreportedasmerely18%.Sinusarrhythmiasinmyocarditisareuncommon.Case report:Herewedescribeacaseofa33-years-oldfemalepatientwithmyocar-ditis.Shedevelopedsinusarrestlastingfor15secondsandlostconsciousnessandaseizurewasobservedinthatperiod.Anewrhythmoccurredspontaneously.Temporarytransvenouspacemakerleadwasimplantedduetorecurrentsinuspauseepisodes.Thepatientwasonsinusrhythmonthethirddayofadmission.CardiacMagneticResonanceImaging(CMRI)showedsubendocardialenhancement,highlyconsistentwithacutemyocarditis.Thepatientwasdischargedwithnormalsinusrhythm.

Why should an emergency physician be aware of this?Thepatientswithmyocarditisshouldbecloselymonitoredinordertolife-threateningarrhythmias.

Received Date: March 30, 2016Accepted Date: June 06, 2016Published Date: June 11, 2016

Citation: FilizKizilirmakYılmaz.,etal.ACaseReportofMyocarditisandSinusArrest.(2016)JHeartCar-diol2(1):46-49.

FilizKizilirmakYılmaz.,etal.

mmol/L(normalrange136-145mmol/L),potassium4,3mmol/L(normalrange3.5-5.1mmol/L,creatinekinase(CK)301(normalrange,26-192U/L),CreatineKinase-MyocardialBand(CK-MB)83(normalrange,7.2µg/L)andTroponin-I(Tn-I)4.2µg/L(nor-malrange,<0.0,23µg/L),serumC-ReactiveProtein(CRP)25.8mg/L(normalrange<5mg/L).ImmunologicalandserologicalinvestigationsincludingANCAandANAtests,Lymeserology,thyroidfunctiontestsandviralserologywerenormal.

Figure 1:ECGs,demonstratingabnormalintraventricularconduction(A),sinusarrest(B),acceleratedidioventricularrhythm(C).

After recordingherbaseline12-leadECG,shedevelopedsinusarrest lasting for15secondswhile shewasstillbeingmonitoredwithECG(Figure1B).Thepatientlostconsciousnessandaseizurewasobservedinthatperiod.Anewrhythmoccurredspontaneouslyandnointerventionwasmade.Cardiacmedicationssuchasatropineorephedrinewerenotusedtoenhancerhythm.New12-leadECGshowedaccelerated idioventricular rhythm(Figure1C).Thepatientwas immediately transferred tocatheterlaboratoryfortemporarypacemakerimplantation.Whilebeingtransferred,sinuspauseepisodesrecurred.Temporarytransvenouspacemakerleadwasimplantedvialeftfemoralaccessbutdesirableleadpositioningcouldnotbeachieved.MeanwhiletotalAVblockwasmonitored.Ongoingeffortsforappropriatepositioningofthecurrentleadwerehelplesssoanothertemporarypacemakerwasimplantedwithrightjugularveinaccess.Confirmingtheappropriatepositionandfunctionofthesecondlead,thefirstleadwaswithdrawn.Thereafter,coronaryangiographywasperformedandnormalcoronaryarteriesweredocumented(Figure2A,2B,2C).Shewastransferredbacktocoronarycareunitwithtemporarypacemakersupport.Temporarypacemakerwasswitched-offandrepeatedECGshowedtotalAVblock(Figure3A).

Figure 2:Coronaryangiographicimages(A,B,C)ofpatient

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On the second day of admission, the patientwas on sinus rhythm (Figure 3B). Intermittent, short-lasting pacemakerrhythmswerenotedonbed-sidemonitorrecordings.Nopacemakerrhythmwasobservedafterthethirddayofadmission.Anti-bioticsorantiviralmedicationswerenotprovided.Herbloodtestsontheseconddaywereasfollows;WBC8.6110e3/µL,hae-moglobin12.3g/dL,plateletcount16010e3/µL,urea33mg/dL,creatinine0.6mg/dL,glucose80.5mg/dL,sodium135mmol/L,potassium4,5mmol/L.LevelsofmyocardialbiomarkersandCRPbegantodecrease(CK:106U/L,CK-MB:14ug/LTn-I:0.22µg/L,CRP19mg/L).

Figure 3:ECGs,demonstratingtotalAVblock(A),sinusrhythm(B).

ThepatientwasscheduledforElectrophysiologicalStudy(EPS)onthefourthdayofadmission.EPSresultswerenotsug-gestiveforpermanentpacemakerimplantation.FirstdegreeAVblock(suprahisianlocalization)wasrecorded.Temporarypacemak-erwaswithdrawnandCardiacMagneticResonanceImaging(CMRI)wasscheduled.CMRIshowedsubendocardialenhancementinlateralandinferiorventricularwalls,highlyconsistentwithacutemyocarditis(Figure4).

Figure 4:CardiacMRIofpatient

ThepatientwasdischargedafternormalizationofECG,laboratorytestsandechocardiographicexaminationonthesixthdayofadmission.Shewasasymptomaticinattheone-monthfollow-upvisit.HerECGandechocardiographicexamswerenormalaswell.

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Discussion Myocarditisisaninflammatorydiseaseofthemyocardiumwhichmayhavevariousclinicalpresentationsrangingfrombeingasymptomatictosuddencardiacdeath.Arrhythmiasassociatedwithsuddencardiacdeathareusuallyventriculararrhythmias(such as ventricularfibrillation)[2].Myocarditis cases presentingwith totalAVblock and syncope had been reported before[3,4]. However,sinusarrhythmiainmyocarditisisextremelyrare.ThereisonecaseofLymemyocarditispresentingwithsinuspausefor8secondsintheliterature[5].Anothercaseseriesincluding20childrenwithsicksinussyndromedetectedmyocarditisin2ofthepatients[6].Ourpatientsuffereddifferentconsecutiverhythmsincludingrepetitivesinusarrest(thelongestonelastingfor15seconds),acceleratedidioventricularrhythm,andtotalAVblock.Althoughourpatienthadbothsinusandventriculararrhythmias,shehadnormalleftventriclesystolicfunctionsandCMRIrevealedenhancementinalimitedmyocardialterritory.Nevertheless,wewereabletoperformCMRIafterwithdrawaloftemporarypacemakerandacutephaseofthedisease.Hence,moreextensiveenhancementcouldbevisualizedifitcouldhavebeenperformedearlier.

Why should an emergency physician be aware of this? Promptidentificationandtreatmentoflife-threateningarrhythmiasassociatedwithmyocarditismaybelife-savingbyclosemonitoringofpatientswithmyocarditis.

References

1. Wu,Lin-Lin,Han,B.Diagnosisandtreatmentofmyocarditis.(2014)ZhongguoDangDaiErKeZaZhi16(12):1283-1288.2. Blauwet,L.A.,Cooper,L.T.Myocarditis.(2010)ProgCardiovascDis52(4):274-288. 3. Akashi,R.,Kizaki,Y.,Kawano,H.,etal.Seizuresandsyncopeduetocompleteatrioventricularblockinapatientwithacutemyocarditiswithanormalleftventricularsystolicfunction.(2012)InternMed51(21):3035-3040.4. Caughey,R.W.,Humphrey,J.M.,Thomas,P.E.High-degreeatrioventricularblockinachildwithacutemyocarditis.(2014)OchsnerJ14(2):244-247.5. Franck,H.,Wollschläger,H.Lymecarditisandsymptomaticsinusnodedysfunction.(2003)ZKardiol92(12):1029-1032.6.Radford,D.J.,Izukawa,T.Sicksinussyndrome.Symptomaticcasesinchildren.(1975)ArchDisChild50(11):879-885.

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MyocarditisandSinusArrest

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