Citation

Cao Y, Liu X, Shi H. Eur. Heart J. Case Rep. 2023; 7(10): ytad479.

Copyright

(Copyright © 2023, Oxford University Press)

DOI

10.1093/ehjcr/ytad479

PMID

37854106

PMCID

PMC10580371

Abstract

A 47-year-old male patient visited our hospital for chest pain and shortness of breath. He experienced syncope in the methane digester 3 days ago. He was previously in good health and had no history of viral colds or autoimmune disorders. No significant abnormalities were found in the sputum culture for bacteria and fungi. Electrocardiogram showed diffuse ST-segment elevations in the precordial and limb leads (Panel A), mimicking acute myocardial infarction. The level of serum ultra-sensitive Troponin I was 79.4 ng/L (normal < 26.2 ng/L), creatine kinase-isoenzymes was 18.7 ng/mL (<6.6 ng/mL) and N-terminal-proBNP was 72.2 pg/mL (<100 pg/mL). Coronary computed tomography angiography (CTA) demonstrated coronary arteries were unobstructed with no atherosclerotic lesion (Panel B). Pulmonary artery CTA revealed the main trunk and branches of the pulmonary artery were normal (Panel C). Balanced steady-state free procession cine magnetic resonance imaging (MRI) demonstrated mild hypertrophy in the left ventricular (LV) myocardium (mid-septum, 12 mm; lateral wall, 11 mm; reference value 4-9 mm), with a normal LV ejection fraction (see Supplementary material online, Movies S1 and S2). T2 short tau inversion recovery MRI revealed diffuse high signal intensity (SI) in the LV myocardium (Panels D-F; SI ratio of myocardium over skeletal muscle = 2.6), suggesting myocardial wall oedema. On mapping sequence, the native T1 (Panels G-I; mid-septum, 1412 ms; lateral wall, 1558 ms, reference value 1105-1280 ms), native T2 Panels J-L; mid-septum, 50 ms; lateral wall, 58 ms, reference value 42-48 ms), and extracellular volume (mid-septum, 38%; lateral wall, 41%; reference value 25-30%) values were globally elevated. First-pass perfusion MRI showed no obvious perfusion defect in the LV myocardium (see Supplementary material online, Movies S3 and S4). Late gadolinium enhancement MRI revealed multiple sub-epicardial hyperenhancement in the LV myocardium (Panels M-O), which strongly suggests a non-ischemic aetiology. Therefore, clinical and cardiac MRI findings suggested the diagnosis of myocarditis associated with exposure to marsh gas poisoning.

Language: en