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Atypical Presentation of Viral Myocarditis in a Young Adult Mandeep Kaur1*, Prema Bezwada2 and Ayala Rodriguez Cesar1

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Atypical Presentation of Viral Myocarditis in a Young Adult Mandeep Kaur1*, Prema Bezwada2 and Ayala Rodriguez Cesar1 ISSN: 2378-3656 Kaur et al. Clin Med Rev Case Rep 2019, 6:284 DOI: 10.23937/2378-3656/1410284 Volume 6 | Issue 9 Clinical Medical Reviews Open Access and Case Reports CASE REPORT Atypical Presentation of Viral Myocarditis in a Young Adult Mandeep Kaur1*, Prema Bezwada2 and Ayala Rodriguez Cesar1 1Department of Cardiology, The Brooklyn Hospital Center, New York, USA Check for 2Department of Internal Medicine, The Brooklyn Hospital Center, New York, USA updates *Corresponding author: Mandeep Kaur, Department of Cardiology, The Brooklyn Hospital Center, New York, United States of America Abstract Case Report Convulsive Syncope can be difficult to distinguish from sei- A 32-year-old female was brought to Emergency De- zures at times. We present a young adult with cardiogenic partment after a cardiac arrest at work. As per cowork- convulsive syncope that mimic seizures. Continuous cardi- ers she suddenly collapsed and had seizure like activity. ac monitoring revealed various arrythmias during seizure like activity. She had a viral prodrome. Cardiac MRI was She was found to be pulseless, so three rounds of CPR diagnostic for myocarditis. More detailed studies for the were performed, and four shocks were delivered. Re- role of a noninvasive cardiac testing such as Cardiac MRI turn of spontaneous circulation was achieved. She re- (CMR) and newer treatment modalities such as anti-thymo- verted to full consciousness spontaneously within min- cyte immunoglobulin are required for the management of Viral Myocarditis. utes without confusion or cognitive deficits. On further enquiry she admitted a one-week history of fever and Case report: A 32-year-old female was brought to the Emergency Department after a cardiac arrest at work. cough. She was evaluated in an Urgent care center and She was found to be pulseless, so three rounds of CPR sent home on Pseudoephedrine. were performed, and four shocks were delivered. While in hospital she had multiple episodes of arrythmias associated En route to the hospital she was noted to have a BP with pulselessness requiring transvenous pacing. She had of 90/60 mmHg and the cardiac monitor revealed poly- a prodrome of viral illness and transferred to a tertiary care morphic Ventricular tachycardia (VT), (Figure 1). She center for cardiac MRI and placement of an Implantable then had an episode of myoclonus and became unre- Cardioverter Defibrillator (ICD). Cardiac MRI revealed signs of early myocarditis. sponsive, went into asystole briefly then polymorphic VT then monomorphic VT (Figure 2), and finally into si- Introduction nus tachycardia (Figure 3). Per EMS this lasted for about 15 sec. Differentiating Cardiovascular Convulsive syncope In the Emergency department, cardiac monitor from Seizure has always been a dilemma [1,2]. We de- showed non-sustained polymorphic ventricular tachy- scribe a case of a previously healthy young woman pre- cardia and then a sustained period of bigeminy quickly senting with a sudden onset of intractable Stokes Adam developing into polymorphic ventricular tachycardia Attack. Vasovagal syncope is the most likely etiology of with tonic movements of her arms and face and was syncope in young women [1]. However detailed history pulseless. CPR and defibrillation were performed with taking in our patient revealed a prodrome of viral ill- resolution to sinus rhythm. She quickly regained con- ness. Later found to have myocarditis on cardiac MRI. sciousness. Total time of pulselessness was less than Myocarditis can have variable presentation [1,3]. This 30 seconds. Cardiac monitoring revealed frequent Pre- case depicts life threatening arrythmias that present mature Ventricular Contractions (PVC) (Figure 4). Point as seizure like episodes. The arrythmias caused as a se- of care ultrasound was performed bedside, which quela of myocarditis. Citation: Kaur M, Bezwada P, Cesar AR (2019) Atypical Presentation of Viral Myocarditis in a Young Adult. Clin Med Rev Case Rep 6:284. doi.org/10.23937/2378-3656/1410284 Accepted: September 07, 2019: Published: September 09, 2019 Copyright: © 2019 Kaur M, et al. This is an open-access article distributed under the terms of the Cre- ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Kaur et al. Clin Med Rev Case Rep 2019, 6:284 • Page 1 of 5 • DOI: 10.23937/2378-3656/1410284 ISSN: 2378-3656 Figure 1: Electrocardiogram recorded by Emergency Medical Services showing Polymorphic Ventricular Tachycardia. Figure 2: Electrocardiogram recorded by Emergency Medical Services showing Monomorphic Ventricular Tachycardia. Figure 3: EKG showing Normal Sinus Rhythm. showed mildly dilated left atrium and left ventricle cardium and skeletal muscle in gadolinium-enhanced with reduced left ventricular ejection fraction (Figure T1-weighted image. A Subcutaneous Implantable Car- 5 and Figure 6). dioverter Defibrillator (ICD) was placed for secondary prevention of arrythmias. Patient was discharged with She was overdrive paced for a day (Figure 7). On close follow up. telemonitoring, Rhythm was sinus rhythm with PVC. IV Amiodarone was also given to control ventricular ar- Discussion rythmias. This case describes a patient with classic Stokes On day 2, TVP was removed and patient was trans- Adam attack associated with a myriad of ventricular ar- ferred to a tertiary care center for a cardiac MRI. Car- rythmias in the setting of viral myocarditis. diac MRI revealed Global myocardial SI increase in Differentiating syncope from seizures can be dif- T2-weighted images and Increased global myocardial ficult at times [1,2]. The Stokes-Adams attack, a form early gadolinium enhancement ratio between myo- Kaur et al. Clin Med Rev Case Rep 2019, 6:284 • Page 2 of 5 • DOI: 10.23937/2378-3656/1410284 ISSN: 2378-3656 Figure 4: EKG recorded in the Emergency department showing Sinus Rhythm with frequent Premature ventricular contrac- tions and prolonged QTc interval. Figure 5: Transthoracic Echocardiogram showing dilated Left atrium. LA Diameter: 2.6 cm. of cardiovascular syncope, classically described as an Our patient exhibited generalized jerking and myoc- abrupt, transient loss of consciousness due to a sudden lonic movements on presentation. The loss of muscle but pronounced decrease in the cardiac output, which tone (atonia) resulting in sudden collapse, the absence is caused by a paroxysmal shift in the mechanism of the of post ictal phase, prompt return of consciousness fa- heart beat [4]. vors syncope over seizure in our patient [1,2]. Kaur et al. Clin Med Rev Case Rep 2019, 6:284 • Page 3 of 5 • DOI: 10.23937/2378-3656/1410284 ISSN: 2378-3656 Figure 6: Transthoracic Echocardiogram showing Dilated Left Ventricle with reduced Ejection Fraction. Left Ventricular Ejection Fraction: 35 percent. Figure 7: EKG showing Ventricular paced rhythm. Treatment of myocarditis consists of both specific carditis/Bacterial superinfections [3]. Unfortunately, we therapy aimed at the cause of the myocarditis and sup- do not have any predictive methods to triage these pa- portive treatment to control Heart failure and arrhyth- tients on initial presentation at urgent care centers. mias [3,5,6]. The Heart Failure Society of America 2010 Conclusion comprehensive heart failure practice guideline recom- mends considering endomyocardial biopsy for patients Literature reveals various presentations of Stokes with acute deterioration of heart function of unknown Adam Attack. A myriad of arrythmias are associated origin that is not responding to medical treatment [6]. with it. AV blocks are more commonly associated than Ventricular arrythmias [4,7]. This case emphasizes the It is a common case scenario where patients are importance of thorough history from multiple avail- dismissed from urgent care centers with common cold able sources because intractable Stokes Adams can remedies to have to return with life threatening Myo- mask an underlying heart conditions such as infection. Kaur et al. Clin Med Rev Case Rep 2019, 6:284 • Page 4 of 5 • DOI: 10.23937/2378-3656/1410284 ISSN: 2378-3656 Cardiovascular magnetic resonance (CMR) has become References the primary tool for noninvasive assessment of myocardi- 1. Caroline A Ball, Livia T Hegerova, Vuyisile T Nkomo (2014) al inflammation in patients with suspected myocarditis. 23-Year-Old Woman With Syncope. Mayo Clin Proc 89: The International Consensus Group on CMR Diagnosis e93-e97. of Myocarditis provides CMR protocol standards, termi- 2. Jaime Toro (2018) Differentiating between syncope and nology for reporting CMR findings, and diagnostic CMR convulsive seizures. Neurology. criteria for myocarditis (i.e., “Lake Louise Criteria”) [8]. 3. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, et al. (2018) Harrison’s Principles of Internal Medicine. (20th Current standard treatment of viral myocarditis is edn), New York, NY. supportive care, although immunomodulatory thera- 4. Harbison J, Newton JL, Seifer C, Kenny RA (2002) Stokes pies, such as steroids and intravenous immunoglobu- Adams attacks and cardiovascular syncope. Lancet 359: lin, are often used [6,9]. A systematic review concluded 158-160. that there are insufficient data from methodologically 5. O’Connell JB (1998) Diagnosis and medical treatment of inflammatory cardiomyopathy. In: Topol E, Nissen J, Car- strong studies to recommend routine IVIG therapy in diovascular Medicine. Lippincott-Raven, Philadelphia. patients with acute myocarditis. However, there are no 6. Maisch B, Alter
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