A CURIOUS CASE OF MYOCARDITIS WITH ELEVATED ANTISTREPTOLYSIN O TITERS

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Acute rheumatic fever can cause a spectrum of rheumatic heart disease, including myositis, pericarditis, or valvulitis. It is mostly seen in children and is considered a disease of poverty. Here, we present a case of a 24 year-old with myocarditis secondary to rheumatic fever. CASE PRESENTATION: A 24 year-old male presented to the emergency department because of chest pain that started 2 nights prior. His pain was rated 8/10, nonradiating, worse with inspiration and associated with nausea. It was the first time he had experienced chest pain. The patient was recently discharged from the the hospital because of acute tonsillitis, where he experienced throat pain, fever, nausea, vomiting, cervical and submandibular lymph node swelling. He was discharged with improvement of his tonsillitis after treatment with clindamycin. He has no significant past medical history. On physical examination, the patient’s temperature was 38.2*C and heart rate was 103 bpm with the rest of physical examination being unremarkable. Chest X-ray showed bilateral pulmonary congestion with cardiomegaly but no infiltrates or consolidation. EKG revealed diffuse ST segment depression. Laboratory studies showed an elevated white count with normal neutrophil and lymphocyte counts. Troponin levels were elevated from 0.359 ng/mL and peaked to 0.447 ng/mL. Urine toxicology was negative. Blood cultures were taken but returned negative. He was admitted to the telemetry unit with elevated troponin levels to rule out acute coronary syndrome. Cardiology performed an echocardiogram, showing no structural or functional abnormalities; a cardiac catheterization showed the patient had nonobstructive CAD. Throughout his hospital stay, he had fluctuating temperatures, with a Tmax of 38.9*C and developed right knee pain and then pain in the left knee two days later. X-rays were taken of both knees, demonstrating moderate effusion of the right knee. Infectious disease was consulted and recommended ASO titers, influenza Ag, stool culture, and gonorrhea and chlamydia urine PCR. All results of the laboratory test were negative except for the ASO titer of 1:200, CRP of 309.1 mg/dL, and ESR of 114 mm/hr. He was started on naproxen as well as benzathine penicillin G with a diagnosis of myocarditis secondary to rheumatic fever. The patient showed much improvement throughout the course of hospital stay and was discharged to follow up with cardiology and infectious disease clinics. DISCUSSION: The differential diagnosis for a young adult with chest pain is usually secondary to drugs or chest wall pain. It is very unusual for a young adult to present with myocarditis secondary to rheumatic fever, which is more commonly seen in children. It is pertinent to consider acute myocarditis associated with GAS tonsillitis as a differential. CONCLUSIONS: An early diagnosis and treatment can significantly improve the prognosis of the patients. Reference #1: Jose L. Aguirre, MD, Margarita Jurado, MD, Mateo Porres-Aguilar, MD, Cristina Olivas-Chacon, MD, Mateo Porres-Muñoz, MD, Debabrata Mukherjee, MD, and  Juan Taveras, MD. Acute nonrheumatic streptococcal myocarditis resembling ST-elevation acute myocardial infarction in a young patient. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Hung-I Liao, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response