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Myocarditis: Acute

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Okay, this next case is the case of a 14

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year old male who presented to the emergency department with chest pain.

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Eventually, he was worked up.

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They found that he had an elevated troponin of around 70. Very high.

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And then the concern was that he had acute myocarditis.

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Cardiac MRI was ordered to confirm the diagnosis.

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This is not uncommon reason to perform cardiac MRI.

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We get quite a few referrals for this.

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And the main things that we're looking

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for are, we want to see T1 abnormalities and T2 abnormalities.

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The T1 abnormalities are going to be the late gadolinium enhancement,

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and the T2 abnormalities are going to be the edema.

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And so, we're going to start here with the cine four chamber view.

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And what you can see is that the patient has nice preserve function.

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I'll tell you that acute myocarditis

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almost every case I can think of that I've ever seen, they have preserve function.

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So generally, in the acute phase,

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you're going to have pretty normal myocardial function

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if it is an acute viral myocarditis

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in a child. There is such an entity as chronic myocarditis.

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So kids that get myocarditis, and then for whatever reason, the infection doesn't

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clear. Those kids can get reduced cardiac function.

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But generally, that first presentation, they're going to have normal function.

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What you can see here, though,

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and this is before we've given any gadolinium, is that there is this bright

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signal here in the lateral wall of the left ventricle.

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So remember that these SSFP images are

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a combination of both T2 and T1 weighting.

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So if you see any bright signal in the myocardium on the pre-contrast

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imaging, usually that means it's going to be edema.

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So that T2 signal abnormality kind

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of almost like shines through the background on these SSFP images.

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What is part of the standard evaluation

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of patients who have myocarditis is the black blood imaging.

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The black blood T2 weighted images are used to look for edema.

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In this case, this patient has really extensive and bright edema in the lateral

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wall of the left ventricle here in the subepicardial space.

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And this is a classic for myocarditis.

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Myocarditis love to involve the sub epicardium of the lateral wall,

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particularly at the base, mid cavity and apex.

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And it's often this sort of linear pattern

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where it's not so much a blob, it's not discrete nodules.

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It's really this linear pattern along

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the length of the subepicardial surface of the lateral wall.

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Now, if we move ahead to the two chamber

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cine view, you're going to see that, again, the function is preserved.

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And then when we look at the short axis

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cine images, again, the function is preserved. Normal wall thickness.

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But you do see that bright signal in the lateral wall shining through

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again. When we move to the short axis late

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enhancement images, you're going to see that there's quite

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a bit of enhancement in this patient, in a pattern very consistent with myocarditis.

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And that pattern is subepicardial lateral wall and inferior wall.

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Classic for myocarditis, particularly at the base and the mid cavity.

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This patient's actually got basal sparing, which is sometimes a little bit unusual,

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but the remainder of the case is normal and typical, where you have this lateral

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wall involvement stretching around to the inferior wall

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really extensive.

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Even a little bit of mid wall involvement of the septum.

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And that's really classic for myocarditis.

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And certainly, in the clinical setting of having an elevated troponin and chest

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pain, this is basically makes the diagnosis.

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I just want to show you that late enhancement on the long axis images.

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It's right here.

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All this subepicardial late enhancement, it corresponds to the abnormalities

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that we saw on the T2 weighted black blood imaging.

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So we have a T2 abnormality.

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We have a T1 abnormality.

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Those are the key components of making the diagnosis of myocarditis.

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So, in summary, this patient has

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late enhancement in the lateral wall and a non-ischemic subepicardial distribution,

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with edema in the same areas compatible with acute myocarditis.

Report

Faculty

Stefan Loy Zimmerman, MD

Associate Professor of Radiology and Radiological Science

Johns Hopkins Medicine Department of Radiology and Radiological Science

Tags

Non-infectious Inflammatory

Myocardium

MRI

Infectious

Cardiac

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