A Case of Reversible Very Low Voltage Electrocardiogram in Fulminant Myocarditis
A 53-year-old Korean-Chinese woman was brought into the emergency department of our hospital by an ambulance, with complaints of progressive chest pain and dyspnea. She had a high fever, cough, and general fatigue over the three days. Upon arrival, she was fully conscious and had signs of cold sweating, cyanosis and general pallor. The initial creatine kinase (CK), CK-MB and Troponin-I levels were 626 U/L, 47.27 ng/mL, >50 ng/mL, respecitvely. Emergent coronary angiogram was performed because of low blood pressure (88/56 mm Hg), ST-segment depression in the precordial leads of ECG (), and systolic dysfunction with left ventricular wall motion abnormality on echocardiography. Coronary angiographic findings were normal, and an intra-aortic balloon pump (IABP) was immediately inserted for hemodynamic support (). On the basis of prodromal symptoms, elevated cardiac enzymes and normal coronary angiographic findings with ventricular wall motion abnormality, we contemplated acute decompensated heart failure due to clinical suspicion acute myocarditis. She was admitted to the coronary care unit, and mechanical ventilation and inotropic agents were started. Although aggressive supportive therapies were provided, her blood pressure continued to decline. We decided to support the patient with ECMO, which was inserted in a veno-arterial configuration by cannulation on both femoral vessels. We were able to reduce the amount of inotropic agents using mechanical circulatory support. However, ECG showed wide QRS tachycardia with left bundle branch block (), and echocardiography showed severe global hypokinesia (). The serum creatinine level was elevated, and the amount of urination was decreased. Soon after, pulmonary edema developed. Because of low blood pressure and the lack of diuretic effect, continuous renal replacement therapy was started using the ECMO circuit on day 1. Ventricular wall movement was gradually decreased, and ECG showed little or no electrical activity ( and ). On day 2, IABP had to be removed because of its malfunction. We continued intensive supportive care. However, the laboratory data and general medical conditions gradually deteriorated. ECG showed little or no electrical activity. On day 5, ECG revealed weak electrical activities (), and echocardiography showed a slight improvement of systolic function (). She gradually recovered, and her ECG showed sinus rhythm ( and ). Since then, her condition started to gradually recover. Mechanical ventilator was weaned off on day 18, and ECMO was weaned off on day 20. She underwent cardiac magnetic resonance imaging after making sure that she was medically stable, which showed diffuse wall thinning, decreased wall motion and delayed enhancement of diffuse ventricular wall sparing of the infero-septal wall (). During hospitalization, she was complicated with ischemic insult in the lower extremities, hepatitis with jaundice, and acute tubular necrosis. On day 76, she was discharged from the hospital. The ejection fraction on the echocardiogram before discharge was approximately 30%. She receives wound dressing once a day and maintains hemodialysis every other day.