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Case Report Open Access A Rare Case of Non-rheumatic Streptococcal Acute Sandra Mazzoni* and Heather S Laird-Fick Department of Medicine, Michigan State University, East Lansing, MIEW Sparrow Hospital, Lansing, Michigan, USA *Corresponding author: Sandra Mazzoni, Department of Medicine, Michigan State University, East Lansing, MIEW Sparrow Hospital, Lansing, Michigan, USA, Tel: 5173535100; E-mail: [email protected] Rec date: June 02, 2016; Acc date: June 15, 2016; Pub date: June 22, 2016 Copyright: © 2016 Mazzoni S et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Non-rheumatic Streptococcal Acute Myocarditis, also known as Strep Acute Myocarditis (SPAM) occurs in young adults, typically within five days of the initial streptococcal pharyngitis, and is characterized by typical cardiac symptoms, abnormal , and elevated cardiac biomarkers in the absence of obstructive . Patients may also report myalgias, , and constitutional symptoms. Although a rare of Group A and G streptococcal , prompt recognition is important to ensure appropriate management. This article discusses the case of a 33-year-old male who presented with substernal and monoarticular two days after diagnosis with streptococcal pharyngitis, and reviews available literature on the evaluation and management of SPAM.

Keywords: Myocarditis; Streptococcal

Background Non-rheumatic Streptococcal Acute Myocarditis, also known as Strep Pharyngitis Acute Myocarditis (SPAM), occurs in young adults and is more common in males. It presents with sub-sternal chest pain associated with nausea, dyspnea, myalgias or arthalgias. ST segment elevation is present on electrocardiogram, identical to the changes found with acute . Symptoms of SPAM typically present within 5 days of the initial streptococcal infection. This is a rare complication of Group A and G Strep infections; however, based on literature review it is likely more prevalent as many cases remain undiagnosed at the time of presentation [1-3].

Case Presentation A previously healthy 33 years old male presented to the emergency Figure 1: Electrocardiogram at time of admission with ST elevation department after awakening with sub-sternal chest pain and tightness in anterior and inferior leads with ST depression in V1 and V2. radiating to his left arm. Associated symptoms included nausea, dyspnea and pain in his left knee. An emergent transthoracic echocardiogram (Figure 2) showed mild Two days previously he had been evaluated at a local urgent care for apical hypokinesis, without systolic dysfunction, valvular dysfunction a and was started on oral amoxicillin based on a positive or pericardial changes. The patient was taken for a cardiac rapid strep A test; his sore throat had resolved. catheterization with angiography which revealed no angiographic On examination, vital signs were stable. was regular rate and evidence of coronary artery disease. Cardiovascular magnetic rhythm without murmurs, rubs or gallops. Lungs were clear to resonance could not be performed to confirm clinical diagnosis of . The left knee exam was benign, without effusions, myocarditis due to local unavailability of the equipment [4]. erythema or increased warmth. Based on ST segment elevation, elevated cardiac biomarkers, The electrocardiogram (Figure 1) revealed ST segment elevation in normal angiography, and failure to meet the Revised Jones Criteria for the anterior and inferior leads and ST segment depression in V1 and diagnosis of Acute Rheumatic (ARF) [5], the patient was V2. Labs revealed a peak troponin-I of 22.0, creatine phosphokinase of diagnosed with Non-Rheumatic Streptococcal Acute Myocarditis 857 and CK-MB of 14.2. (SPAM). He was treated with oral amoxicillin and non-steroidal anti- inflammatories with resolution of his chest pain.

Fam Med Med Sci Res Volume 5 • Issue 3 • 1000203 ISSN:2327-4972 FMMSR, an open access journal Citation: Mazzoni S, Laird-Fick HS (2016) A Rare Case of Non-rheumatic Streptococcal Acute Myocarditis. Fam Med Med Sci Res 5: 203. doi: 10.4172/2327-4972.1000203

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As for uncomplicated cases of streptococcal pharyngitis, remains the first line antimicrobial agent, as supported by several case series [3,6,7]. Alternatives include cephalosporins and, for patients with severe penicillin , . The first line anti- inflammatory agent should be a non-steroidal anti-inflammatory drug (i.e. naproxen sodium, ibuprofen) although remain an option for those with contraindications such as bleeding or kidney disease. While in these patients is generally self- limited, treatment with beta blockers, angiotensin converting enzyme inhibitors/angiotensin blockers and (for symptom control) is warranted [3].

Conclusion Figure 2: Mild hypokinesis of the apical segment of the left ventricle with normal wall motion of the rest of the left ventricle. There needs to be a high suspicion for Non-Rheumatic SPAM when a young adult presents with cardiac symptoms within a few days of confirmed streptococcal pharyngitis. Acute Rheumatic Fever needs to be ruled out using the Revised Jones Criteria. In the setting of ST Discussion segment elevation on electrocardiogram and elevated cardiac Diagnosis of SPAM requires three things: exclusion of rheumatic biomarkers, obstructive coronary artery disease should be excluded fever, confirmation of preceding streptococcal infection, and evidence with either coronary angiography or CMR. CMR is the gold standard of myocardial involvement not due to obstructive coronary artery for diagnosing myocarditis and confirming its resolution. Treatment disease. Rheumatic fever is ruled out using the Revised Jones criteria includes penicillin and anti-inflammatories. for diagnosis of ARF [5]. Of note, acute rheumatic fever typically has a 2-3 week latency period, while SPAM’s is typically less than 5 days. References Group A or Group G streptococcal infection can be confirmed by typical symptoms in combination with a positive rapid detection test or culture. 1. Aguirre J, Jurado M, Porres-Aguilar M, Olivas-Chacon C, Porres-Munoz M, et al. (2015) Acute non-rheumatic streptococcal myocarditis Cardiac Magnetic Resonance (CMR) with focal subepicardial late resembling ST-elevation acute myocardial infarction in a young patient. gadolinium enhancement is the gold standard for diagnosis of Baylor University Medical Proceedings 28: 188-190. myocarditis [3]. Since this specialized test is not widely available, other 2. Chaudhuri A, Dooris M, Woods ML (2013) Non-rheumatic streptococcal findings that support the diagnosis include: 1) electrocardiogram with myocarditis - warm hands, warm heart. J Med Microbiol 62: 169-172. ST segment elevation and reciprocal changes; 2) echocardiography 3. Mokabberi R, Shirani J, Haftbaradaran MA, Go BD, Schiavone W (2010) with new wall motion abnormalities or hypokinesis; and 3) normal Streptococcal pharyngitis-associated myocarditis mimicking acute coronary angiography. STEMI. JACC Cardiovascular Imaging 3: 892-893. 4. Boruah P, Shetty S, Kumar SS (2010) Acute streptococcal myocarditis Two case series support the use of CMR for confirming resolution of presenting as acute ST-elevation myocardial infarction. J Invasive Cardiol myocarditis as well. Mokaberri et al. reported eight patients with 22: 189-191. SPAM confirmed with CMR with focal subepicardial late gadolinium 5. Special Writing Group of the Committee on Rheumatic Fever, enhancement in whom follow-up CMR confirmed resolution of , and of the Council on Cardiovascular myocarditis [3]. Similarly, Upadhay et al. reported a case series of nine Disease in the Young of the American Heart Association (1992) patients, three of whose diagnosis was confirmed using Cardiac Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 Magnetic Resonance. Two of these had repeat testing that confirmed update. JAMA 268: 2069-2073. resolution [6]. 6. Upadhyay GA, Gainor JF, Stamm LM, Weinberg AN, Dec GW, et al. (2012) Acute nonrheumatic streptococcal myocarditis: STEMI mimic in Treatment for SPAM focuses on eradication of the streptococcal young adults. Am J Med 125: 1230-1233. infection, use of anti-inflammatories, evidence-based medical 7. Khan ZZ, Bronze MS (2015) Group A Streptococcal Infections. management for non- as needed, and Medscape. documentation of resolution of the myocarditis.

Fam Med Med Sci Res Volume 5 • Issue 3 • 1000203 ISSN:2327-4972 FMMSR, an open access journal