A RARE CASE OF EPSTEIN BARR VIRAL MYOCARDITIS-INDUCED CARDIOGENIC SHOCK

Abstract

SESSION TITLE: Case Report Semifinalists 8 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Epstein barr virus (EBV) is a ubiquitous virus whose clinical association ranges from infectious mononucleosis to lymphomas and nasopharyngeal carcinomas. We present a case of EBV associated myocarditis, hepatitis, disseminated intravascular coagulation (DIC) and multiple system organ failure (MSOF). CASE PRESENTATION: 63-year-old man presented with 1 week of chest pain and dyspnea to our Emergency Room. On initial examination, the patient was alert and oriented, with mild respiratory distress. EKG showed low voltage QRS and diffuse ST depression. CXR showed mild interstitial edema. Serum chemistries showed Hemoglobin 4, White count 0.92, platelet count of 72,000 , Creatinine 2.4, BUN 56, high sensitivity troponin 2665 ng/L, proBNP 29,766 pg/ml, AST 1435, ALT 738, Total bilirubin 17.3, GGTP 26. Hepatobiliary imaging was without evidence of cirrhosis, it did show cholelithiasis, however the patient did not have clinical evidence of acute biliary pathology. He rapidly deteriorated and developed acute hypoxic respiratory failure and encephalopathy requiring admission to the ICU. He was intubated and mechanically ventilated. Point of Care Ultrasound showed diffuse biventricular hypokinesis. His CXR showed worsening pulmonary edema. He was initiated on dobutamine and Lasix infusions. He was also noted to be oozing from all IV sites and his work up was consistent with DIC. He received blood products for correction of coagulopathy. The clinical suspicion for an acute coronary syndrome was low, and he was considered a poor candidate for cardiac catheterization given DIC and renal failure. High dose steroids were initiated for suspicion for myocarditis. Complete infectious workup revealed EBV DNA by PCR. Given profound pancytopenia a bone marrow biopsy was performed which showed reactive plasmacytosis, no blast cells and few histiocytes engulfing red cells. While Hemophagocytic lymphohistiocytosis was considered based on his bone marrow biopsy results, further cytological studies revealed 20q chromosomal deletion consistent with myelodysplastic syndrome (MDS). The patient responded to therapy and was successfully extubated, dobutamine infusion was weaned off and renal function recovered. Unfortunately the patient developed multiple embolic infarcts. Patient and his family opted for discharge to hospice where he died one week later. DISCUSSION: EBV related myocarditis and MSOF represents a rare, potentially fatal complication of a usually benign, self-limiting disease. In our patient, acute EBV infection may have been reactivated in the setting of immunocompromise, however the possibility that chronic EBV infection played a role in the development of MDS cannot be excluded. CONCLUSIONS: EBV is a rare cause of myocarditis and MSOF. Appreciation of the potential virulence of the pathogen, prompt diagnosis and better therapeutics are necessary for management of this fatal presentation of EBV. Reference #1: Angelini, A., Calzolari, V., Boffa, G., Maddalena, F., Chioin, R., & Thiene, G. (2000). Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis. Heart (84), 245-250. Reference #2: Miller, R., Ward, C., Amsterdam, E., Mason, D., & Zelis, R. (1973). Focal mononucleosis myopericarditis simulating myocardial infarction. . Chest (63), 102-105. Reference #3: Sabbatini, S., Manfredi, R., Ortolani, P., Trapani, F., & Viale, P. (2012). Myopericarditis during a primary Epstein-Barr virus infection in an otherwise healthy young adult. An unusual and insidious complication. Case report and a 60 year literature review. Le Infezioni in Medicina (2), 75-81. DISCLOSURES: No relevant relationships by Shaeesta Khan, source=Web Response No relevant relationships by Ritika Paul, source=Web Response