A Very Rare Complication of Hepatitis a Infection: Acute Myocarditis

Abstract

Hepatitis A is a common viral infection with a benign course but in rare cases can progress to acute liver failure. A rare manifestation of hepatitis A is acute myocarditis. We report a case of a 30-year-old female, without significant past medical history who presented with four days of fatigue, myalgias, nausea, non-bloody, non-bilious emesis and non-bloody diarrhea along with anorexia. Physical exam was significant for mild scleral icterus and right upper quadrant abdominal tenderness, without peritoneal signs or fluid wave. She had intact mentation, no asterixis or stigmata of liver disease. Lab work revealed severe elevations in liver transaminases, AST = 6,769U/L, ALT = 8.479U/L., INR = 2.0 and acute viral hepatitis panel was positive for hepatitis A IgM only. EBV IgG and IgM were positive but heterophile assay and EBV PCR was negative (Figure 1 and 2). Abdominal US revealed homogenous hepatic echotexture without evidence of focal hepatic lesions. There was mild intrahepatic biliary ductal dilatation with common bile duct measuring 2mm. On her 3rd day of admission the patient developed chest pain and nonspecific ECG changes. Her troponin rose to 16.4 ng/mL, and an echocardiogram revealed global hypokinesis and a depressed ejection fraction (EF) at 30%. A coronary CT angiography showed no evidence of significant coronary artery disease. The patient was managed supportively and symptoms and laboratory findings slowly improved over the next 7 days. Her chest pain resolved and follow up echocardiogram showed improved EF to 45%. To our knowledge, there are 3 case reports of myocarditis associated with hepatitis A (Figure 3). Like previous case reports, a presumptive diagnosis of myocarditis secondary to hepatitis A was made, despite endomyocardial biopsy (EMB) being the gold standard for definitive diagnosis. However, EMB is not always indicated especially if it would not change management. Despite improving liver indices, the patient developed myocarditis. Therefore, it may be worthwhile to monitor patients for cardiac abnormalities despite signs of improving transaminases. Comparison of these case reports also highlights that higher elevations in transaminases may be associated with more severe cardiomyopathy. However, given the rarity of this manifestation, true associations are yet to be elucidated. The purpose of this case report is to increase awareness of this disease entity, so it can be recognized and considered in clinical practice.2305_A Figure 1. Key laboratory values on admission.2305_B Figure 2. Trend of liver function tests and troponin obtained during hospital course. Day 1 is day of admission. Day 17 is outpatient follow up.2305_C Figure 3. Other reported cases of myocarditis in hepatitis A.