Vol. 41 | No. 2 | July-December 2013 Back

Open Access

When STEMI is not STEMI: HIV Myocarditis Mimicking ST elevation Myocardial Infarction on Electrocardiogram: A Case Report

Jaime Alfonso M. Aherrera, Deonne Thaddeus Gauiran, Agnes D. Mejia
Dec 2013 DOI 10.69944/pjc.146788ccae

Abstract

BACKGROUND: Myocarditis is a common occurrence among human immunodeficiency virus (HIV) infected patients, which either resolves spontaneously or results in death. Anecdotal reports have shown that myocarditis can mimic acute myocardial infarction (MI) with chest pain and electrocardiographic (ECG) abnormalities. We present a case of HIV myocarditis unusually presenting with transient ST-segment elevations and cardiogenic shock. 

CASE: We present a 42 year old male who sought consult due to chronic dyspnea. He has had recurrent pneumonias for the previous 4 months, associated with weight loss and undocumented febrile episodes. HIV testing on admission was positive and he was managed as a case of pneumocystis pneumonia. Chest x-ray showed interstitial infiltrates and cardiomegaly. Electrocardiogram (ECG) suggested left ventricular hypertrophy (LVH) with Q-waves in lead V1-V3. Troponin-I at this time was within normal. 

Co-trimoxazole was started with note of slight improvement in symptoms. On the fourth hospital day, he was referred for worsening dyspnea and desaturations. He had a blood pressure of 170/100 mmHg, and had supraclavicular retractions and crackles, distended neck veins, distinct heart sounds, and an S3 gallop. Electrocardiogram showed ST segment elevations on the anteroseptal wall. Assessment at this time was an ST elevation MI (STEMI). 

A few hours after, the blood pressure suddenly dropped to 60 mmHg (palpatory) associated with worsening dyspnea. Inotropic support was started and he was subsequently hooked to mechanical ventilator. 

A repeat ECG done 6 hours after revealed similar findings to that of the first ECG (Q-waves on septal wall with LVH). Troponin-I was taken at baseline, at 12 hours, and at 24 hours after the onset of ST elevation, and none were significantly elevated (0.34, 0.32, and 0.50 mcg/L respectively; with a normal reference range of 0-0.3 mcg/L). Echocardiogram done while on inotropic support showed a depressed ejection fraction with global hypokinesia. 

The patient was diagnosed with HIV myocarditis. He was managed supportively for the fulminant heart failure. Three days after, he went into sudden cardiac arrest leading to his demise. 

KEYWORDS: Myocarditis, myocardial infarction, human immunodeficiency virus.

References
  1. Dec GW Jr1, Waldman H, Southern J, Fallon JT, Hutter AM Jr, Palacios I. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol. 1992 Jul;20(1):85-9. 
  2. Spencer S, Miller A, Blackwell M. Be Still My Heart. SGIM Forum 2012;35:1-3. 
  3. Ardhanari S, Kumar NA, Udyavar AR, Latchumanadhas K.HIV Myocarditis Presenting as Acute ST-Segment Elevation Myocardial Infarction. Indian Heart J. 2006 May-Jun;58(3):269-71. 
  4. Magnani JW, Dec GW. Myocarditis: Current Trends in Diagnosis and Treatment. Circulation. 2006 Feb 14;113(6):876-90. 
  5. Dec GW, Waldman H, Southern J, Fallon JT, Hutter AM, Palacios I. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol 1992;20:85–89. 
  6. Angelini A, Calzolari V, Calabrese F, Boffa GM, Maddalena F, Chioin R, Thiene G. Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis. Heart 2000;84:245–250. 
  7. Sarda L, Colin P, Boccara F, Daou D, Lebtahi R, Faraggi M, Nguyen C, Cohen A, Salma MS, Steg PG, LeGuludec D. Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms. J Am Coll Cardiol 2001;37:786–792. 
  8. Costantini, M. Myocarditis with ST-Elevation Myocardial Infarction presentation in young man. A case series of 11 patients. Int J Cardiol 2005;101:157-8. 
  9. Testani JM, Kolansky DM, Litt H, Gerstenfeld EP. Focal myocarditis mimicking acute st-elevation myocardial infarction: diagnosis using cardiac magnetic resonance imaging. Tex Heart Inst J 2006;33:256-9. 
  10. Martinez-Quintana E, Rodriguez-Gonzalez F, Junquera Rionda P. Persistent electrocardiographic ST segment elevation from previous myocarditis. Ann Pediatr Card 2013;6:74-6.
License

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, which permits use, share — copy and redistribute the material in any medium or format, adapt — remix, transform, and build upon the material, as long as you give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. You may not use the material for commercial purposes. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/.