Recurrent Myocarditis Imitating ST Myocardial Infarction
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The present case has been reported in the Journal of Medical Cases.

A 29-year-old obese, but otherwise healthy male without history of medication use or substance abuse presented to the emergency room with sudden onset substernal chest pain at rest, accompanied by vomiting, left arm weakness, and fatigue. One week prior to admission he had transient upper respiratory symptoms.

Electrocardiogram (ECG) revealed diffuse ST-elevations, most prominent in the inferior leads. Troponin I was elevated to 8.45 ng/mL. An echocardiogram was unremarkable with only a trivial pericardial effusion. Given concern for myocarditis, CMR was obtained for diagnosis and prognostication. This demonstrated patchy late gadolinium enhancement (LGE) in the epicardium of the mid-to-apical inferior walls consistent with myocarditis. He was treated NSAID as needed and colchicine as he was initially felt to have a component of pericarditis.

After 2 months without symptoms, the patient presented again with chest pain, similar to the prior presentation, albeit more intense. ECG showed 3 mm ST segment elevations in the inferior leads and 1 mm in the lateral leads with no appreciable PR depression, concerning for an inferior ST elevation myocardial infarction (STEMI).

Troponin peaked at 39.5. His ECG evolved overnight with the development of Q waves and T wave inversions. There was a new inferior wall motion abnormality on echocardiogram. Due to concern for possible STEMI, cardiac catheterization was performed, revealing normal coronary arteries without evidence of thrombus or vasospasm.

Repeat CMR revealed inferior and anteroseptal hypokinesis and evidence of focal areas of progressive LGE in the mid-basal inferior walls, along with increased T1 and T2 values consistent with acute myocarditis. There was patchy-like multi-focal LGE involving the basal inferior wall, distal inferior wall, and septum with regions of epicardial LGE, supporting the diagnosis of myocarditis.

Telemetry demonstrated no cardiac conduction abnormalities during his hospitalization. He was discharged on an angiotensin-converting enzyme (ACE) inhibitor and beta blocker. His symptoms soon resolved. At a follow-up clinic visit, his ECG revealed large inferior Q-waves.

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