Acute Epstein-Barr related myocarditis: An unusual but life-threatening disease in an immunocompetent patient

Abstract

Myocarditis is an uncommon but potentially life-threatening disease. Clinical manifestations could range from subclinical disease to sudden death, due to fulminant heart failure and/or malignant ventricular arrhythmias. The most common cause of myocarditis is viral infection, including Epstein-Barr virus (EBV). Nevertheless, EBV rarely presents with cardiac involvement in immunocompetent hosts. We report a case of acute EBV-related myocarditis in a young female, complicated with malignant ventricular arrhythmias and cardiac arrest. After 20 days of hospitalization and treatment, the patient was fit for discharge on pharmacological therapy (tapering steroids, beta-blockers, amiodarone, angiotensin-converting enzyme inhibitors, and diuretics). Clinical course is described, cardiac magnetic resonance images are shown. This case underlines how myocarditis is a disease that should not be underestimated: it could present with life-threatening complications such as malignant arrhythmias and/or severe systolic dysfunction. <Learning objective: Although Epstein-Barr virus rarely presents with cardiac involvement in immunocompetent hosts, the risk should not be underestimated, as it could present with life-threatening complications.>.

Keywords: Cardiac arrest; Epstein-Barr; Heart failure; Myocarditis; Viral infection.

Fig. 1

Instrumental findings. (A) Electrocardiogram at the hospitalization. (B) View from the echocardiogram performed at the admission. The interventricular septum appears thinned and hyper-reflective (C) Ventricular tachycardia and shock. (D) Bedside chest X-ray at the admission to the intensive care unit. It shows bilateral pleural effusion and signs of pulmonary interstitial edema. (E,F) Cardiac magnetic resonance imaging. Frames from a cine series at the end-diastole (E) and end-systole (F), showing severe reduction of left ventricular function (30%) with associated global hypokinesia.

Fig. 2

Cardiac magnetic resonance imaging, late gadolinium enhancement - short axis (A,B) and 4 chambers (C). The images show global and diffuse enhancement with a subepicardial – intramyocardial pattern of distribution (white arrows), that involve all cardiac walls, except a little portion of the basal and apical septum (black arrows, C). Subendocardium is preserved (arrowheads, A,B).