Spontaneous coronary hematoma concomitant with myocarditis: the first report of double cardiac complication of dengue

Abstract

We reported the case of a 33-year-old male who presented a dengue infection complicated by spontaneous coronary artery intramural hematoma associated with acute myocarditis. The initial presentation was a typical acute coronary syndrome with ST-segment elevation. Coronary angiography and endocoronary optical coherence tomography confirmed the diagnosis of left anterior descending artery intramural hematoma. Cardiac magnetic resonance imaging revealed not only typical ischaemic injury but also lesions of acute myocarditis confirmed by native T1- and T2-mapping, sub-epicardial late gadolinium enhancement and pericardial effusion. This case highlights the multiple cardiac damages caused by dengue virus, their possible association (coincidental or linked?), and the impact of multimodal imaging on diagnosis and management.

Keywords: Acute coronary syndrome; Dengue infection; Dengue myocarditis; Intramural hematoma; Spontaneous coronary artery dissection.

Figure 1

(A) Initial electrocardiogram showing persistent ST‐segment elevation in precordial leads. (B) Baseline angiography with left anterior descending (LAD) coronary artery hematoma (red arrow). (C) Coronary CT scan with axial view centred on proximal LAD artery, with coronary artery hematoma (red arrow). (D) Compressive hematoma confirmed by optical coherence tomographic imaging, with parietal thrombus in true lumen. The axial view of LAD corresponds to the green arrow. The artery is delimited by a red circle. (E) Transmural late gadolinium enhancement of the infero‐apical wall (white arrow) with a no‐reflow phenomenon (subendocardial hypoenhancement) traducing ischaemic injury related to the coronary artery intramural hematoma. (F) Native T1‐mapping showing increased T1 values principally in mid‐anterior wall, corresponding to myocarditis lesions. (G) Four‐chamber view of cardiac magnetic resonance imaging with apico‐lateral sub‐epicardial late gadolinium enhancement (blue arrow), consistent with the diagnosis of myocarditis. (H) Magnetic resonance imaging short‐axis view revealing a mild pericardial effusion (asterisk).