A STEMI gone viral

Abstract

A 65-year-old male with a history of coronary artery disease and ankylosing spondylitis presented with focal ECG changes and elevated cardiac biomarkers suggestive of an acute lateral ST-elevation myocardial infarction. Emergent coronary angiography surprisingly showed non-obstructive coronary artery disease. Further workup including a cardiac MRI, viral serologies, and an endomyocardial biopsy was consistent with focal Coxsackie viral myocarditis. The patient subsequently developed recurrent, pulseless ventricular tachycardia requiring multiple rounds of ACLS, and his left ventricular ejection fraction acutely dropped from 55% to 20%. An emergent intra-aortic balloon pump was placed, and an intravenous lidocaine infusion and high-dose corticosteroids were started for the patient’s electrical storm and myocarditis, respectively. The patient was eventually discharged in stable condition with an implantable cardiac defibrillator. No further episodes of ventricular tachycardia were noted at six-month follow-up. In patients with acute ECG changes, elevated cardiac biomarkers, and no evidence of obstructive coronary artery disease, myocarditis should be considered as a leading diagnosis given the potentially life-threatening sequelae as seen in our patient.