Abstract 10031: Parvovirus Causing Severe Cardiogenic Shock With Recovery

Abstract

Parvovirus B19 infection is common worldwide with the majority of people infected as young children. Its clinical presentation varies widely depending on the patient’s age and immune competence. Parvovirus B19 infection has been associated with myocarditis; however, its causal mechanism is unclear. A 57 year-old man who recently returned from Bolivia presented after five syncopal episodes. His initial troponin was elevated at 11.2 ng/mL. Electrocardiogram showed third degree heart block with a fascicular escape rhythm at 40 beats per minute. Echocardiogram revealed an ejection fraction of 45-50% and global hypokinesis of the left ventricle. Left heart catheterization showed mild non-obstructive coronary artery disease. His transvenous pacemaker was exchanged for a permanent pacemaker a few days later only to discover a repeat ejection fraction of 15-20%. The patient’s condition progressed to cardiogenic shock requiring inotropic and mechanical support. A comprehensive myocarditis workup was pursued which included a negative full respiratory viral panel, along with negative serum tests for coxsackievirus, hepatitis, human immunodeficiency virus, tuberculosis, syphilis, Lyme disease, strongyloidiasis and fungi. Urine toxicology prior to admission was negative for cocaine. Thyroid function tests were normal. Endomyocardial biopsy showed severe myocarditis with lymphocyte predominance. Staining was negative for fungi, spirochetes, Trypanosoma cruzi, herpes simplex virus, cytomegalovirus, or amyloid. There were no multinucleated giant cells seen on light microscopy. Subsequent PCR of DNA isolated from the biopsy specimen was positive for parvovirus (495 copies/100ng DNA) and Epstein-Barr virus (2046 IU/100ng DNA). His serum EBV viral load was undetectable. His parvovirus IgM level was negative and IgG level was positive. A diagnosis of fulminant parvovirus myocarditis was made. The patient was treated with steroids and five days of IVIG. Repeat echocardiogram showed recovery of his ejection fraction to 50-55%. Our case illustrates a complicated and rare case of fulminant parvovirus myocarditis in a previously healthy and active adult who luckily had recovery of his ejection fraction within 1 month.