A 44-Year-Old Man With Persistent Upper Respiratory Infection

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After a week with flu-like symptoms, a 44-year-old man presents to the emergency department with severe fatigue, lower extremity swelling, and marked dyspnea on exertion.
After a week with flu-like symptoms, a 44-year-old man presents to the emergency department with severe fatigue, lower extremity swelling, and marked dyspnea on exertion.

B. Fulminant viral myocarditis

Myocarditis is an inflammatory condition that may result in decreased cardiac output and even cardiogenic shock as in this patient. The failure to maintain adequate perfusion pressures ultimately results in a systemic inflammatory reaction that is responsible for vasodilatation and further myocardial depression.1

As a result, the overall mortality in patients with myocarditis presenting with cardiogenic shock is approximately 50% to70%.2 Initial therapy includes vasopressors and inotropes aimed at increasing myocardial contractility and systemic vascular resistance to maintain perfusion pressures.1 Mechanical circulatory support is indicated when medical therapy fails at improving the cardiac output. Acute severe mitral insufficiency secondary to ruptured papillary muscle is typically seen as a complication of late presenting acute coronary syndrome (ACS).

While possible, ACS is not the most likely etiology in this patient given the lack of chest pain, the lack of risk factors, and progressive nature of his symptoms in the setting of sick contacts and an unrelenting upper respiratory illness. Cardiac sarcoidosis rarely presents acutely and is often asymptomatic. The disease is usually suspected in patients with other forms of sarcoid presenting with heart block or other arrhythmias. 

References

  1. Chaparro SV, Badheka A, Marzouka GR, et al. Combined use of Impella left ventricular assist device and extracorporeal membrane oxygenation as a bridge to recovery in fulminant myocarditis. ASAIO J. 2012;58(3):285-287.
  2. Nakamura T, Ishida K, Taniguchi Y, et al. Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support: a retrospective single-center study. J Intensive Care. 2015;3(1):5. 
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