Myocarditis patient with left ventricular, right atrial, and pericardial thrombi

Excerpt

A 26-year-old male patient presented with fatigue and shortness of breath on minimal exertion lasting for 2 weeks following a flu-like infection. A physical examination revealed sinus tachycardia with a heart rate of 120 betas/min, blood pressure of 100/50 mmHg, elevated jugular venous pressure, bilateral rales in the lower lung fields, mild hepatomegaly, and bilateral pretibial edema. Electrocardiography showed sinus rhythm and left bundle branch block. Transthoracic and transesophageal echocardiography revealed left ventricular systolic dysfunction (ejection fraction: 20 %) with global hypokinesia, multiple giant mural thrombi in the left ventricular apical region adherent to the wall, and multiple mobile cystic thrombi in the right atrium and posterior pericardial space within the effusion (Fig. 1, Videos 1–4). Laboratory testing yielded the following results: creatinine, 1.5 mg/dl (0.5–1.1); aspartate aminotransferase (AST), 100 U/l (10–37); alanine aminotransferase (ALT), 266 U/l (10–40); C-reactive protein (CRP), 123 mg/l (0–5); white blood cell count (WBC), 13,600 ul; hemoglobin, 13.4 g/dl; creatine kinase-MB (CK-MB), 12 mg/l (0–5); troponin T, 345 mg/l (0–14); and NT-proBNP, 35,000 pg/ml (0–400). The rest of the laboratory examination results were normal. Screening for hypercoagulability states was negative. Because of the patient’s recent infection history, markedly decreased ejection fraction, and increased inflammatory markers and cardiac enzymes, we considered myocarditis as the most logical explanation for the clinical scenario. The patient was treated with warfarin, ramipril, carvedilol, and furosemide. Within a few days his clinical condition improved and all laboratory parameters returned to normal limits (NT-proBNP levels decreased to 12,340 pg/ml).Follow-up transthoracic echocardiography performed 1 month later showed complete lysis of the right atrial and left ventricular thrombi, marked regression in the pericardial fluid and intrapericardial thrombus size, and significant improvement in the left ventricular systolic function (ejection fraction: 40 %) (Fig. 2, Video 5). To our knowledge, there are no previous reports of simultaneous left ventricular, right atrial, and pericardial thrombi in the same patient. …