Fulminant myocarditis—Case report

A 46-year-old woman was admitted due to diplopia because of ophthalmoplegia, which improved with corticosteroid therapy. Eight days later, she was admitted with fulminant myocarditis in cardiogenic shock, with severe left ventricular dysfunction and frequent episodes of nonsustained ventricular tachycardia. As there was no clinical improvement, an endomyocardial biopsy was performed that revealed inflammatory infiltrate, vasculitis, and PCR positive for cytomegalovirus, Epstein–Barr virus, parvovirus B19 and enterovirus. Left ventricular function recovered with heart failure treatment and corticosteroids. Three months later, after progressive withdrawal of prednisolone, there was recurrence of myocarditis and left ventricular dysfunction, which was successfully treated by restarting corticosteroid therapy. One month later she was readmitted with fulminant myocarditis which again responded to steroids. She intermittently presented cutaneous purpura lesions. At this time the provisional diagnosis was vasculitis and she started monthly cycles of cyclophosphamide. Before the second cycle, she was admitted with pneumonia and ventricular dysfunction and died.

ResumoMulher de 46 anos foi internada por diplopia devido a oftalmoplegia, que melhorou com corticoterapia. Oito dias depois, iniciou quadro de miocardite fulminante associada a choque cardiogénico por disfunção ventricular esquerda grave e episódios frequentes de taquicardia ventricular não mantida. Por não apresentar melhoria clínica, foi submetida a biópsia endomiocárdica que revelou infiltrado linfocitário, sinais de vasculite e PCR positiva para citomegalovírus, vírus Epstein-Barr, enterovírus e parvovírus. Após tratamento da insuficiência cardíaca e corticoterapia, recuperou a função ventricular. Três meses depois e após a suspensão de prednisolona, teve recorrência da miocardite com disfunção ventricular, tratada com sucesso após reinício de corticóides. Um mês depois, foi reinternada com o mesmo quadro que respondeu ao aumento da dose de corticóides. Apresentou intermitentemente lesões cutâneas tipo púrpura. Colocou-se a hipótese de vasculite e iniciou tratamento com ciclos mensais de ciclofosfamida. Antes do segundo ciclo, foi internada com pneumonia associada a disfunção ventricular e faleceu.