Mesalamine-induced Myocarditis in a Young Athlete: Can He Run Again?

Abstract

Mesalamine is often used in the treatment of inflammatory bowel disease (IBD). Mesalamine-induced cardiotoxicity has been reported in the literature and is a rare entity. The mechanism of cardiotoxicity remains unclear, however, it is believed to be due to a humoral-mediated hypersensitivity reaction. Patients with mesalamine-induced cardiotoxicity could present with a wide range of cardiovascular symptoms ranging from mild chest pain and shortness of breath (SOB) to cardiogenic shock secondary to left ventricular systolic dysfunction. Symptoms could be associated with elevation in cardiac biomarkers and electrocardiogram (EKG) changes including ST-segment or T-wave abnormalities. We report a case of mesalamine-induced myocarditis in a young athlete presenting with chest pain 10 days after mesalamine therapy was initiated for recently diagnosed Crohn’s disease. Workup was significant for elevated cardiac biomarkers. The diagnosis was confirmed with cardiovascular magnetic resonance imaging (CMR). Immediate cessation of the medication resulted in resolution of symptomatology and normalization of cardiac biomarkers over a 48-hour period. Mesalamine-induced cardiotoxicity is a rare, yet serious side effect that necessitates medical community awareness. CMR is the confirmatory diagnostic modality of choice.

Analysis of clinical characteristics of mesalazine-induced cardiotoxicity

“…Identifying the primary cause of mesalazine-induced cardiotoxicity is challenging because cardiotoxicity is a rare manifestation of IBD ( Sorensen and Fonager, 1997 ; Oh et al, 2012 ). Cardiotoxicity from IBD typically manifests itself as pericarditis, myocarditis, myocardial infarction, and heart failure ( Ibrahim et al, 2019 ; Rogler et al, 2021 ). Cardiac adverse reactions in patients with IBD treated with mesalazine are rare.…”

Recurrent myocarditis in a patient with active ulcerative colitis: a case report and review of the literature

“…12 MSZ induced myocarditis usually appears within 4 weeks from the beginning of the treatment, but concomitant corticosteroid use could delay the onset of the cardiotoxicity. MSZ-induced myocarditis has been reported in literature both in the treatment of UC, [8][9][10][11][12][13][14][15][16] Crohn's disease [17][18][19] and in newly diagnosed IBD. 21 Up to now, more than 51 cases of MSZ induced myocarditis have been reported.…”

“…2 Despite rare, cardiac extraintestinal manifestations, such as pericarditis and myocarditis, are more commonly reported to occur in UC than Crohn's disease patients. 7 In addition, in patients with IBD myocarditis could be triggered by drugs currently used to treat this condition [8][9][10][11][12][13][14][15][16][17][18][19] such as mesalazine (MSZ) or biological agents, 20 and in newly diagnosed IBD. 21 Last but not least, Coxackie viruses, Parvovirus B19, Adenoviruses and enteroviruses can be aetiological agents for myocarditis.…”