A RARE CASE OF FULMINANT MYOCARDITIS CAUSED BY MYCOPLASMA PNEUMONIAE SUCCESSFULLY TREATED WITH IVIG

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fulminant myocarditis (FM) is a clinical condition which main characteristic is a rapidly progressive clinical course associated with hemodynamic compromise and high mortality risk.It is associated with an infectious process but rarely reported alongside Mycoplasma pneumoniae infection.It is unclear if the primary problem is ongoing damage from a virus, post-infectious inflammatory reactions, or both. Therefore,immunosuppressive therapy such as IVIG could be of potential benefit for treating FM.We report a rare case of FM caused by M.pneumoniae in a 27 y/o F showing improvement with IVIG therapy. CASE PRESENTATION: 27 y/o F with DM1 presented to ED with lethargy,hypotension,and tachycardia.Labwork showed DKA.She was intubated, transferred to the ICU and then started on insulin drip.On day 2, the she developed ST segment elevations,along with elevated troponin(11.86 ug/L).Echocardiogram showed EF of 42% along diffuse hypokinesis. Cardiac angiogram revealed nonobstructive CAD.On day 3, DKA resolved and patient was transitioned off insulin drip. Echocardiogram revealed worsened EF of 10-15%.Her workup showed positive M. pneumoniae IgM serology and doxycycline therapy was started, however she developed hemodynamic instability and was started on IVIG therapy.On day 4,she was weaned off vasopressor support and extubated.Repeat echocardiogram revealed EF>50% without wall motion abnormalities.Patient completed 2 days of IVIG therapy and was discharged after 8 days of hospitalization. DISCUSSION: Despite FM’s rareness, up to 12% of cases of sudden death in patients aged <40 years exhibit myocarditis.Our patient was admitted to the ICU with severe DKA, and within 24 hours she developed FM with positive M. pneumoniae IgM serology. M. pneumoniae is among the most common bacterial causes of respiratory tract infections and also associated with carditis. Myocarditis should be suspected in patients with or without cardiac signs and symptoms who present a rise in cardiac biomarker levels; changes in ECG or abnormalities of ventricular systolic function. Definitive diagnosis of myocarditis is achieved via endomyocardial biopsy(EMB).Yet, 2013 ACCF/AHA guidelines suggest excluding other causes of HF as EMB might be helpful when the results influence the management.Therefore,our patient underwent heart catheterization to rule out obstructive CAD upon the documented STEMI findings.IVIG therapy was started when she worsened hemodynamically.Yet, the use of IVIG for acute myocarditis should not be part of routine practice as its use is obscured by poor quality evidence making its use for infectious myocarditis debatable. CONCLUSIONS: The response to IVIG therapy suggests that the rapid decline of this case of infectious FM may be caused in part by an autoimmune process.Immunosuppressive treatment with IVIG in FM associated to M.pneumoniae may reduce the mortality rate and prevent irreversible myocardial injury. Reference #1: Veronese, G. (2018). Fulminant myocarditis: Characteristics, treatment, and outcomes. The Anatolian Journal Of Cardiology. https://doi.org/10.14744/anatoljcardiol.2017.8170 Reference #2: Tretjak, M., Verovnik, F., Vujkovac, B., Slemenik-Pusnik, C., & Noc, M. (2003). Severe Diabetic Ketoacidosis Associated With Acute Myocardial Necrosis. Diabetes Care, 26(10), 2959-2960. https://doi.org/10.2337/diacare.26.10.2959 Reference #3: Gupta, A., Ghimire, G., & Hage, F. (2013). Guidelines in review: 2013 ACCF/AHA Guideline for the Management of HF. Journal Of Nuclear Cardiology, 21(2), 397-399. https://doi.org/10.1007/s12350-013-9832-x DISCLOSURES: No relevant relationships by Sabree Abedrabo, source=Web Response No relevant relationships by Violeta Alvarez-Retamales, source=Web Response No relevant relationships by Mukul Bhattarai, source=Web Response No relevant relationships by Phyo Kyaw, source=Web Response No relevant relationships by Odalys Lara-Garcia, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response No relevant relationships by Mingchen Song, source=Web Response