A 40-year-old Woman with Chest Pain, ST Elevation, Elevated Troponin and Normal Coronary Arteries: A Case Report

Abstract

Electrocardiographic changes resembling myocardial ischemia or infarction can be caused by a variety of causes other than ischemia. One of them is acute myocarditis which further confounds clinical judgment by causing elevation in troponins as well. We report a case of myocarditis which underscores the importance of identifying the clinical presentation of acute myocarditis and the electrocardiographic changes that can be associated with it. Case ReportA 40-year-old mother of two children with no significant past medical history presented to an outside hospital (OSH) complaining of intermittent chest pain for a week. She described it as "pressure-like" pain in the retrosternal and epigastric regions, with no radiation and reported it had been particularly worsening in the past two days. She notes that her youngest child aged three was sick with an upper respiratory infection in the past week. On arrival at the OSH, patient's electrocardiogram (EKG) showed significant ST elevations in V1 and V2, ST depression and T wave inversion in the inferior and other precordial leads. (Figure 1) Her initial troponin was 28.6 ng/ml (normal rangeless than 0.5 ng/ml). Anticoagulation was initiated with heparin and an emergent cardiac catheterization was performed at the OSH, which revealed normal coronary arteries.During the procedure, she developed hemodynamic instability, requiring an infusion of norepinephrine and phenylephrine and a placement of an intra-aortic balloon pump (IABP). Patient was then transferred to our institution for further management. Subsequently, she started experiencing repeated episodes of sustained ventricular tachycardia, requiring multiple boluses and continuous infusions of amiodarone. She also developed an irregular tachyarrhythmia with right bundle branch block (Figure 2 and 3). Laboratory work and other cardiovascular studies from OSH were reviewed. Echocardiogram revealed an ejection fraction of 15-20% with severe global LV dysfunction. A presumptive diagnosis of acute myocarditis was made. On the second day of admission, extra-corporeal membrane oxygenation (ECMO) was initiated due to further hemodynamic deterioration.Viral titers for adenovirus, cocksackie, Cytomegalovirus (CMV), herpes, echovirus, Epstein-Barr virus, hepatitis, parainfluenza and varicella were sent. Antibody titers for Lyme, mycoplasma and toxoplasma were also sent. The titers were positive only Figure 1. EKG 1 at the time of initial presentation to the OSH. EKG shows sinus tachycardia with ST elevation in V1 and V2, ST depression in V3 to V6, I, II, III, aVF.