Eosinophilic Myocarditis With Rapid Progression to Cardiogenic Shock, Managed With Mechanical Support and High-Dose Corticosteroids
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A 19-year-old woman with no significant medical history was admitted to the University of Vermont Medical Center with 3 weeks of abdominal pain, vomiting, and diarrhea, as well as 2 to 3 days of chest pain. Her only medication was oral contraceptives, which she had taken for the past 2 years. At presentation, her blood pressure was 97/78 mm Hg and heart rate 107 beats per minute and regular. Physical examination was remarkable for mild generalized pallor, diffuse abdominal tenderness, elevated jugular venous pressure, and a gallop rhythm. Laboratory results revealed a total white blood cell count count of 16.6 K/mm3 (Reference, 4.0-10.4 K/mm3), absolute eosinophil count of 8.52 (Reference, 0.03–0.61 K/mm3), troponin I of 9.99 (Reference, <0.034 ng/mL), and IgE of 241 (Reference, <158 IU/mL). Initial ECG revealed ST-segment elevation in leads I, II, III, aVF, and V4 through V6, ST depression in leads V1 through V3, and mild PR-segment depression (Figure 1A). A chest computed tomographic scan was negative for pulmonary embolism.
Within a few hours of admission, the patient’s condition deteriorated rapidly, with development of worsening hypotension and tachycardia (blood pressure, 86/42 mm Hg; heart rate 134 beats per minute). Echocardiography revealed a trivial pericardial effusion, left ventricular (LV) ejection fraction of 30% to 35% with diffuse hypokinesis and marked thickening of the septum and posterior wall consistent with intramyocardial edema, and reduced LV cavity size (Figure 2A and 2B). Because of worsening hemodynamics, the patient was emergently transferred to the Tufts Medical …