[Skip to Content]
[Skip to Content Landing]

The Devil Hides in the Details—Rare Electrocardiogram Findings in a Patient in Their 50s

To identify the key insights or developments described in this article
1 Credit CME

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).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

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 (zhangyi0428@126.com).

Published Online: July 18, 2022. doi:10.1001/jamainternmed.2022.2720

Conflict of Interest Disclosures: None reported.

References
1.
Chen  C , Zhou  Y , Wang  DW .  SARS-CoV-2: a potential novel etiology of fulminant myocarditis.   Herz. 2020;45(3):230-232. doi:10.1007/s00059-020-04909-zPubMedGoogle ScholarCrossref
2.
Nakashima  H , Honda  Y , Katayama  T .  Serial electrocardiographic findings in acute myocarditis.   Intern Med. 1994;33(11):659-666. doi:10.2169/internalmedicine.33.659PubMedGoogle ScholarCrossref
3.
Olgin  JE , Zipes  DP . Specific arrhythmias: diagnosis and treatment. In: Mann  DL , Zipes  DP , Libby  P , Bonow  RO , Braunwald  E , eds.  Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Elsevier; 2015:748-797.
4.
Baher  AA , Uy  M , Xie  F , Garfinkel  A , Qu  Z , Weiss  JN .  Bidirectional ventricular tachycardia: ping pong in the His-Purkinje system.   Heart Rhythm. 2011;8(4):599-605. doi:10.1016/j.hrthm.2010.11.038PubMedGoogle ScholarCrossref
5.
Hang  W , Chen  C , Seubert  JM , Wang  DW .  Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes.   Signal Transduct Target Ther. 2020;5(1):287. doi:10.1038/s41392-020-00360-yPubMedGoogle ScholarCrossref
6.
Klein  HO , Di Segni  E , Kaplinsky  E , Schamroth  L .  The Wenckebach phenomenon between electric pacemaker and ventricle.   Br Heart J. 1976;38(9):961-965. doi:10.1136/hrt.38.9.961PubMedGoogle ScholarCrossref
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close