A patient in their 50s presented to the emergency department with dyspnea, palpitations, fatigue, and syncope for 4 days. Ten days prior, the patient developed a fever after experiencing symptoms of an upper respiratory tract infection. They had no history of cardiovascular disease. On presentation, the patient’s blood pressure was 98/65 mm Hg, heart rate was 65 beats per minute, and body temperature was 36.6 °C. In addition, their serum troponin I level was 12.8 ng/mL (normal range, <0.10 ng/mL; to convert to µg/L, multiply by 1.0) and N-terminal pro–B-type natriuretic peptide was 13 800 pg/mL (normal range, <300 pg/mL; to convert to ng/L, multiply by 1.0). Transthoracic echocardiography showed a left ventricular ejection fraction of 34% with hypokinesia of the interventricular septum and left anterior and right ventricular walls. Coronary angiography showed no stenosis. The patient’s blood pressure dropped to 60/40 mm Hg after admission to the hospital. The initial electrocardiogram (ECG) (Figure, A) showed a wide QRS complex tachycardia. One day later, the patient developed complete atrioventricular block, for which they required temporary pacing. When the patient returned to the ward, an ECG was obtained (Figure, B).
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Fulminant myocarditis is the most severe type of myocarditis. It can lead to cardiogenic shock, ventricular tachyarrhythmias or bradyarrhythmias, as well as sinus arrest and sinoatrial and atrioventricular blocks, and multiorgan failure due to sudden and severe inflammation of the myocardium. The condition can be fatal.1 The current patient did not present with low QRS voltage and abnormal Q waves, which are the typical ECG manifestations in patients with FM.2 Instead, ventricular arrhythmias, including ventricular premature beats, ventricular tachycardia, BVT, and ventricular fibrillation, as well as atrioventricular block, were observed. In addition, the patient developed ventricular pacemaker exit block after temporary pacemaker implantation, which is an even rarer manifestation.
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Corresponding Author: Yi Zhang, PhD, Department of Cardiology, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Clinical Medicine Research Center of Heart Failure of Hunan Province, Hunan Normal University, No. 61 Jiefang West Rd, Changsha City, Hunan Province 410000, China (email@example.com).
Published Online: July 18, 2022. doi:10.1001/jamainternmed.2022.2720
Conflict of Interest Disclosures: None reported.
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