Achy Breaky Heart: A Case of Lymphocytic Myocarditis Mimicking Takotsubo Cardiomyopathy

Abstract

<h3>Introduction</h3> Myocarditis is an inflammatory disease of the myocardium that may be due to immune system activation, infection or exposure to toxic substances. The clinical presentation and trajectories encompass a wide spectrum. We present a case of cardiogenic shock fulfilling both the Mayo criteria for myocarditis and the WHO criteria for Takotsubo cardiomyopathy, distinguished by endomyocardial biopsy. <h3>Case Report</h3> A 65-year-old female with a history of mitral valve repair, hypertension and diabetes presented with acute onset chest pain and dyspnea. She denied recent viral illness. Upon examination, she was tachycardic with elevated JVP, crackles bilaterally, and bilateral lower extremity edema. EKG showed sinus tachycardia with PVCs and anteroseptal/lateral ischemic changes. Labs revealed troponin peaking in the 90s and leukocytosis. She underwent left and right cardiac catheterization revealing essentially clean coronaries, severely reduced LVEF 10-20%, severe hypokinesis of the inferoapical segments consistent with Takotsubo cardiomyopathy and hemodynamics consistent with cardiogenic shock. Cardiac MRI demonstrated findings consistent with myocarditis. The patient was successfully managed by a multidisciplinary team. Due to differential diagnoses of Takotsubo cardiomyopathy and myocarditis, serologies for cardiotropic viruses, urine toxicology, and autoimmune workup were performed and were negative. Therefore, an endomyocardial biopsy was obtained revealing lymphocytic and histiocytic infiltrates with localized areas of fiber necrosis. The lymphoid infiltrates were predominantly T-cells, highlighted with CD45 and CD3 stains, consistent with findings of lymphocytic myocarditis. <h3>Summary</h3> This case highlights lymphocytic myocarditis presenting similarly to Takotsubo cardiomyopathy in an older female. This is particularly thought-provoking given that myocarditis must be excluded in all cases of Takotsubo cardiomyopathy per the Mayo criteria. It illustrates the importance of recognizing the clinical presentation of myocarditis and distinguishing it from other secondary cardiomyopathies to properly manage these patients.