Mesalamine-Induced Cardiogenic Shock in an Ulcerative Colitis Patient

Abstract

Myocarditis is a rare complication of mesalamine therapy. Case reports describe a mild myocarditis presenting with fatigue, chest pain, or arrhythmias. We report a rare case of mesalamine induced myocarditis presenting with cardiogenic shock. A 53 years old female with ulcerative colitis (UC) presented with chest pain, fever, tachycardia and hypotension. She was diagnosed with UC about 3 years prior to admission at which time she was treated with mesalamine. After 2 months she stopped her medications and remained in clinical remission. Two weeks prior to this admission, she was admitted for a UC flare and was restarted on oral mesalamine 3.6gm daily and 4gm rectally. She was also started on tapering doses of prednisone. Her UC symptoms improved however she gradually developed progressively worsening chest pain. Initial lab work revealed WBC count of 11,300/ml, elevated troponins of 15 ng/ml, ESR of 113 mm/hr and CRP of 46.7mg/dl. EKG was notable for sinus tachycardia, PR depression and low voltage. Chest radiograph revealed cardiomegaly with pulmonary congestion. An echocardiogram demonstrated diffuse hypokinesis with a left ventricular ejection fraction (LVEF) of 40%. She was admitted to the ICU where vasopressors and broad spectrum antibiotics were started. Blood and urine cultures were negative and she continued to require hemodynamic support. On hospital day 3, mesalamine was discontinued due to its association with myocarditis. Two days following the discontinuation of mesalamine therapy the patient's condition improved. Vasopressors were discontinued, EKG findings returned to normal, and cardiac enzymes and leukocytosis trended down. Subsequent cardiac catheterization confirmed normal coronary arteries. After 2 weeks, her echocardiogram showed improvement in LVEF to 55%. Cardiac involvement is a rare extra-intestinal manifestations of inflammatory bowel disease (IBD), generally it manifests as pericarditis, pericardial effusion or pericardial tamponade. Myocarditis is even rarer in patients with IBD and it is thought to be secondary to treatment with mesalamine. In the presented case, the proximity of symptoms onset to the initiation of treatment and the resolution of myocarditis with discontinuation of mesalamine points to mesalamine as the culprit. This case is significant as it highlights the need for prompt recognition of mesalamine induced myocarditis as a life threatening condition and the need for immediate discontinuation.