A Case of Heart Failure and Diarrhea

Abstract

A 20 year-old-man with no significant past medical history was admitted with a 5 day history of intermittent chest pain and dyspnea. He also reported a 3 month history of diarrhea with multiple, loose, watery, non-bloody bowel movements daily. He denied recent travel, antibiotic use, medication changes, illicit drug use, or significant alcohol consumption. Physical examination was notable for tachycardia and III/VI apical systolic murmur. Laboratory evaluation was pertinent for hemoglobin 10 g/dL with an MCV of 75.5 fL, NT-proBNP of 18,995 pg/mL, INR of 2.3, albumin of 2.5 g/dL, C-reactive protein of 91.3 mg/L, AST of 66 u/L, ALT of 62 u/L, IgA level of < 1 mg/dL, tissue transglutaminase IgG level > 100 u/mL and anti-gliadin IgG level was 90.5 U. Total levels of IgG and IgM were normal. Upper endoscopy demonstrated a scalloped and mosaic pattern mucosa in the duodenum and biopsies showed total villous atrophy, increased intraepithelial lymphocytes, and crypt hyperplasia consistent with celiac disease. He was started on gluten-free diet with rapid resolution of diarrhea. Transthoracic echocardiogram was notable for an ejection fraction of 21%, severe generalized global hypokinesis and mildly dilated left ventricle. Cardiac MRI demonstrated endocardial delayed enhancement of the left ventricular wall concerning for infarction of the circumflex territory. Coronary angiography demonstrated normal coronary arteries. Right ventricular biopsy showed moderate lymphocytic myocarditis. Patient was initiated on furosemide, metoprolol, lisinopril and discharged from the hospital. He had follow-up echocardiogram one month later. This showed an ejection fraction of 23% and incidental finding of left ventricular apical thrombus. He was initiated on warfarin therapy. One month later, he was admitted with worsening dyspnea, lower extremity edema, and 10 pound weight gain. Echocardiogram demonstrated an ejection fraction of 11%. He maintained strict adherence to a gluten-free diet. He was initiated on immunosuppression with azathioprine 100 mg and prednisone 60 mg with a 4 month taper. He had progressive improvement in fluid retention and resolution of dyspnea. Follow-up echocardiogram one month later demonstrated improved ejection fraction of 34%. This case highlights the association of autoimmune myocarditis with celiac disease. If cardiac function does not improve with a gluten-free diet alone then immunosuppression should be initiated.