Case Report: Fulminant Myocarditis Successfully Treated With Extracorporeal Membrane Oxygenation in Ikeda Strain Orientia tsutsugamushi Infection

Abstract

Scrub typhus is an acute zoonotic febrile illness caused by Orientia tsutsugamushi having a specific geographic endemic area. This infection could be complicated with multi-organ involvement including myocarditis with variable severity. Here, we report a rare case of scrub typhus with biopsy-proven acute fulminant myocarditis which progressed very rapidly to cardiac arrest and was treated successfully with extracorporeal cardiopulmonary resuscitation. Clinicians should be alert to possible rapid progression of scrub typhus myocarditis to fulminant form and be prepared for close monitoring and temporary mechanical support if indicated.

Keywords: Orientia tsutsugamushi; case report; extracorporeal membrane oxygenation; fulminant myocarditis; scrub typhus.

Figure 1

Skin lesions at presentation. (A) 1 × 1 cm sized erythematous to black colored ulcerative lesion covered with crust was observed on his scrotum. (B,C) Diffuse maculopapular rash on the trunk and back.

Figure 2

Summary of disease course. Major events and therapeutics are summarized in the figure. BSI, Bloodstream infection; ECMO, Extracorporeal membrane oxygenation; EMB, endomyocardial biopsy.

Figure 3

Echocardiography. (A) Echocardiography at presentation showed normal left ventricular (LV) wall thickness and chamber size. (B) Echocardiography 6 h before cardiac arrest showed normal LV wall thickness. (C) Echocardiography just after extracorporeal CPR showed thickened LV (13.6 mm, posterior wall, 11.8 mm septum) and right ventricle wall.

Figure 4

Endomyocardial biopsy. Inflammatory cell infiltration consisting of T-lymphocyte within interstitium and myocardium (A-X40, Hematoxylin-Eosin) (B-X200, Hematoxylin-Eosin), with an indication of lymphocyte (black arrow).