Persistent electrocardiographic ST segment elevation from previous myocarditis
An asymptomatic 16-year-old male patient was referred for evaluation because of his past history. He had undergone aortic coarctation surgery by the Waldhausen technique when he was 15 days old.\nAt the age of 11, the patient went to the pediatric emergency department for chest pain associated with dyspnea. At admission then, the patient was afebrile, hemodynamically stable, and denied any previous history of flu-like episodes, fever, or diarrhea in the previous months. However, the electrocardiogram (ECG) showed a ST elevation in the anterior leads; this is the reason why he was admitted for further evaluation. In the next 24 hours, the chest pain spontaneously and progressively disappeared and two repeated creatine phosphokinase (CPK) assessments were within normal limits. Angiography showed normal coronary arteries, a preserved left ventricular function, absence of the left subclavian artery, and no aortic recoarctation.\nNow 5 years later after his hospital admission, the patient is asymptomatic and has had no recurrence of chest pain or dyspnea. There is no history of diabetes, hypertension, dyslipidemia, or smoking. Physical examination is unremarkable with no murmurs or pericardial friction rubs. Analytical data shows normal creatinine, troponin, NT-pro brain natriuretic peptide, and cholesterol concentrations. Antinuclear antibodies are negative. Viral serological tests is positive for Epstein-Barr virus IgG, Coxsackievirus A9 and B (1-6) IgG, Echovirus IgG, Parvovirus B19 IgG, Human Herpes virus 6 (HHV-6) IgG and Rubeola IgG and negative for Epstein-Barr virus IgM, Coxsackievirus A9 and B (1-6) IgM, Echovirus IgM, Parvovirus B19 IgM, Human HHV-6 IgM, Hepatitis A IgG/M, Hepatitis B, Human Immunodeficiency virus (HIV) and Human Cytomegalovirus IgG/M. Meanwhile, bacterial and parasite serological tests are positive for Mycosplasma pneumoniae IgG, Chlamydia pneumoniae IgG, and Rickettsia conorii IgG and negative for Chlamydia pneumonia IgM, Chlamydia trachomatis IgG/M, Chlamydia psittaci IgG/M, Coxiella burnetii IgG/M, Rickettsia typhi IgG/M, Borrelia burdorferi IgG/M, Rickettsia conorii IgM, Leptospira IgM, and toxoplasma IgG/M.\nThe ECG shows upward concave ST segment elevation in the anterolateral leads with T wave inversion and an incomplete right bundle branch block [] similar to the ECGs recorded during his hospital admission at the age of eleven previously. The ECG at the time of coarctation surgery was reported as showing right bundle branch block and right atrial enlargement only.\nCardiac magnetic resonance (MR) imaging shows no renarrowing at the aorta, a normal right ventricle, thinning and hypokinesis of the anterior and anteroseptal middle segments of the left ventricular wall and a preserved left ventricular function (70%). Moreover, there was no evidence of myocardial edema, global relative enhancement, or late Gadolinium enhancement. T2-weighted triple-inversion-recovery imaging was used to calculate the myocardial edema ratio (ER), a normal T1-weighted imaging before and after contrast agent administration was used to determine the myocardial global relative enhancement (gRE), and a normal inversion-recovery gradient-echo imaging was used to evaluate areas of late enhancement (LE)[] [].\nTwenty-four hour ambulatory monitoring of arterial pressure shows a daytime and a nighttime normal blood pressure. Meanwhile, treadmill test shows a normal hypertensive response and no arrhythmias during exercise.