Myocarditis, hepatitis, and pancreatitis in a patient with coxsackievirus A4 infection: a case report

Abstract

Viral myocarditis presents with various symptoms, including fatal arrhythmia and cardiogenic shock, and may develop chronic myocarditis and dilated cardiomyopathy in some patients. We report here a case of viral myocarditis with liver dysfunction and pancreatitis. A 63-year-old man was admitted to our hospital with dyspnea. The initial investigation showed pulmonary congestion, complete atrioventricular block, left ventricular dysfunction, elevated serum troponin I, and elevated liver enzyme levels. He developed pancreatitis five days after admission. Further investigation revealed a high antibody titer against coxsackievirus A4. The patient's left ventricular dysfunction, pancreatitis, and liver dysfunction had resolved by day 14, but his troponin I levels remained high, and an endomyocardial biopsy showed T-lymphocyte infiltration of the myocardium, confirming acute myocarditis. The patient underwent radical low anterior resection five weeks after admission for advanced rectal cancer found incidentally. His serum troponin I and plasma brain natriuretic peptide levels normalized six months after admission. He has now been followed-up for two years, and his left ventricular ejection fraction is stable.This is the first report of an adult with myocarditis and pancreatitis attributed to coxsackievirus A4. Combined myocarditis and pancreatitis arising from coxsackievirus infection is rare. This patient's clinical course suggests that changes in his immune response associated with his rectal cancer contributed to the amelioration of his viral myocarditis.

Figure 1

Electrocardiography on admission. Electrocardiography showed atrial fibrillation and an accelerated idioventricular rhythm (62 beats/min), suggesting complete atrioventricular block.

Figure 2

Clinical course of the patient after admission. Levels of serum aspartate aminotransferase (AST; diamonds), alanine aminotransferase (ALT; squares), and creatinine phosphokinase (CPK; triangles) were high. The AST level peaked on day 2, ALT on day 3, and CPK on day 4. The levels of brain natriuretic peptide (BNP) and troponin I (TnI) were highest at admission and subsequently decreased, but did not return to normal. The gamma-glutamyl transpeptidase (γ-GTP) level was moderately elevated during hospitalization. The serum creatinine level returned to normal by day 7.

Figure 3

Abdominal computed tomography (CT) on day 5. Abdominal CT to investigate the cause of epigastric pain showed localized swelling of the pancreatic body and tail, with no cholelithiasis or tumor obstructing the common bile duct or pancreatic duct, suggesting idiopathic pancreatitis.

Figure 4

Histopathological examination of a biopsy specimen from the left ventricle. Low-power view (× 100) (A) and high-power view (× 400) (B) of the biopsy specimen obtained from the left ventricle, stained with hematoxylin and eosin, showing lymphocytic infiltration into the interstitium and mild necrosis of the myocardium. Immunohistochemical staining with anti-CD3 (C) and anti-CD20 antibodies (D). CD3-positive lymphocytes were predominant.