METAPNEUMOVIRUS PNEUMONIA UNMASKING COXSACKIE MYOCARDITIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Myocarditis is an inflammatory condition involving the myocardium which can be due to various causes including infections, toxins, or autoimmune conditions. The most common infective myocarditis in the world is Chagas disease but viral infections are the most common in the US. Here, we present a case of metapneumovirus pneumonia presenting as heart failure which unveiled coxsackievirus B3 myocarditis. CASE PRESENTATION: A 46-year-old African American man presented with a one-month duration of nonproductive cough which was accompanied by acute exertional dyspnea, orthopnea, and atypical chest pain. He had past history of Hypertension, Diabetes, and Asthma which were stable. On initial evaluation, he was afebrile, with a blood pressure of 142/84mmHg, and a heart rate of 105/min. Physical examination revealed normal S1 and S2 with no murmur/gallops. The pulmonary exam was significant for end-expiratory wheezing with no added sounds. Labs were significant for elevated troponin-I at 0.28ng/ml (reference <0.03), elevated d-dimer of 823ng/ml (reference <500ng/ml), elevated brain natriuretic peptide at 300pg/mL, and normal cell counts. EKG revealed sinus tachycardia with no ischemic changes. The chest x-ray was unremarkable. Computed tomography (CT) with angiogram of the chest revealed multifocal pneumonia in the left upper lobe and right lower lobe with no pulmonary embolism. Sputum and blood cultures were negative for bacterial growth. A transthoracic echocardiogram revealed a dilated left ventricle with an ejection fraction (EF) of 30% with severe global hypokinesis. The respiratory viral panel returned positive for human metapneumovirus. A CT coronary angiogram was unremarkable. With no clear reason for his cardiomyopathy, a serum viral PCR was obtained which was positive for the Coxsackie B3 virus. Other viral antibodies including HIV, EBV, CMV, and Parvovirus were undetectable. A cardiac MRI was obtained which showed findings consistent with myocarditis. His EF at three months follow up improved to 50% with complete resolution of his symptoms with appropriate therapy. DISCUSSION: The type B Coxsackieviruses (CVB) were among the most common causes of viral myocarditis in the US but lately, human herpesvirus 6 and parvovirus B-19 are frequently diagnosed agents. Myocarditis can present clinically as fatigue, chest pain, heart failure, cardiogenic shock, arrhythmias, and sudden death.[1] Many cases likely go undetected because of the subclinical or non-specific signs, therefore, the true incidence is unknown. The majority of cases of CVB infection are subclinical and resolve on their own with supportive care. Our patient was treated with diuretics, beta-blockers, angiotensinogen converting enzyme inhibitor, and spironolactone. CONCLUSIONS: This case highlights the importance of evaluation of viral myocarditis in new-onset heart failure where clinical picture can be confounded by pneumonia. Reference #1: Ammirati E, Cipriani M, Moro C, et al. Clinical Presentation and Outcome in a Contemporary Cohort of Patients With Acute Myocarditis: Multicenter Lombardy Registry. Circulation. 2018;138(11):1088-1099. doi:10.1161/CIRCULATIONAHA.118.035319 Reference #2: Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-2648d. doi:10.1093/eurheartj/eht210 DISCLOSURES: No relevant relationships by Ricardo De Castro, source=Web Response No relevant relationships by Simran Kenth, source=Web Response No relevant relationships by Adam Ladzinski, source=Web Response No relevant relationships by Aditya Mehta, source=Web Response