20 yrs old undergraduate presented with one day history of central chest pain and fatigue. The pain was severe and radiates to the left arm. He had subjective fever and malaise 2 days before the onset of chest pain. He was taken to the primary physician who treated for malaria and ordered chest x ray and ECG. The chest x ray was normal but ECG suggest acute heart attack. He was referred to see a cardiologist.
On presentation at TAAL specialist, he was ill looking but breathless. The ESR was 50mm/hr and CRP 12mg/l, normal range < 1.0mg/l. The Troponin I was 1.4ng/ml, normal < 0.1ng/ml. The ECG showed non specific intra-ventricular conduction delay and ST elevation in V1 to V4. The echocardiogram was normal. He was admitted and managed as acute myocarditis. The chest pain resolved with use of ibuprofen. He was observed for 3 days. The ECG became normal after 5 days. The raised ESR and CRP returned to normal after one week. The Troponin I level was < 0.1 after 2 weeks.
Acute myocarditis as seen in this patient can follow viral infection. The presentation can be alarming. In most cases, the patients makes full recovery following treatment. A small number of patients may developed life threatening condition called fulminant myocarditis.
Myocarditis has to be differentiated from heart attack in patients with risk factors for ischemic heart disease. The typical finding of myocarditis on cardiac MRI can be helpful in this differentiation.
