alexa Streptococcal Pharyngitis-Associated Myocarditis Mimicking Acute STEMI
Medicine

Medicine

Family Medicine & Medical Science Research

Author(s): Rasoul Mokabberi, Jamshid Shirani, Afsaneh Haftbaradaran, B Dennis Go, William Schiavone

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Nonrheumatic streptococcal pharyngitis-associated myocarditis (SPAM) is infrequently reported, and its pathogenesis remains unclear. We report 8 young individuals (age 20 to 35 years, 7 men) who presented with SPAM mimicking acute ST-segment elevation myocardial infarction (STEMI) and characterized clinically with nonpleuritic chest pain, focal electrocardiographic (ECG) ST-segment elevation, and biochemical evidence of myocyte necrosis. In each case, coronary arteries were angiographically normal and cardiac magnetic resonance (CMR) imaging showed subepicardial late gadolinium enhancement (LGE). Seven patients had no prior history of cardiovascular disease, whereas 1 had an episode of acute SPAM 6 years prior to the recent presentation. All patients had evidence of recent streptococcal pharyngitis, within 3 to 7 days prior to presentation, and were treated with antibiotics; none satisfied the revised Jones criteria for diagnosis of acute rheumatic fever. Admission ECG showed focal (5 anterolateral, 3 inferior) ST-segment elevation (1 to 2 mm) that resolved over the course of the illness and was followed by T-wave abnormalities without development of Q waves. Transthoracic echocardiography showed regional (2 to 4 segments) left ventricular (LV) wall motion abnormality in all patients (wall motion index 1.12 to 1.24, mean 1.16 ± 0.06, using a 16-segment model); trivial-to-mild mitral regurgitation was present in 4 patients. Total serum creatine kinase (range 176 to 1,573 U/l, mean: 700 ± 449 U/l, normal <225 U/l), creatine kinase MB fraction (range 15.1 to 174 ng/ml, mean 61 ± 53 ng/ml, normal <9.0 ng/ml), and serum troponin-T (range 0.46 to 3.23 ng/ml, mean 1.401 ± 0.95 ng/ml, normal <0.1 ng/ml) levels were elevated in 7, 8, and 8 patients, respectively. Evidence for recent streptococcal infection was obtained from antistreptolysin O titer in 7 patients (range 392 to 2,364 IU/ml, mean 851 ± 745 IU/ml, normal <200 IU/ml), positive throat culture in 3 patients, and positive rapid streptococcal antigen test in 1 patient. Emergent invasive (n = 6) or computed tomographic (n = 1) angiography showed normal epicardial coronary arteries. Coronary angiography was not performed in a 20-year-old man with recurrent SPAM in whom normal coronary arteries had been demonstrated during a similar episode 6 years earlier. CMR was performed within 2 days of presentation in 7 patients. All patients showed a characteristic subepicardial LGE (3 to 8 segments, mean 5 ± 1.6 of 17 LV segments) (Figs. 1A and Figure 1B); LV ejection fraction ranged from 40% to 64% (mean 53 ± 8%) and was mildly reduced in 4 patients. Resting myocardial perfusion was normal in all. Follow-up CMR was performed 12 ± 7 months after initial presentation in 6 patients. In 5 patients, LV systolic function improved, but in aggregate, LV function improvement was not statistically significant (LV ejection fraction: 61 ± 6 vs. 55 ± 5 at baseline, 95% confidence interval [CI]: −2.5 to 13.2; p = 0.14) and in all patients end-diastolic diameter showed a trend to improvement (50 ± 5 mm vs. 53 ± 5 mm at baseline, 95% CI: −6.3 to 0.3; p = 0.06). Follow-up CMR showed fewer LV segments with LGE (2 ± 1 vs. 5 ± 1.6 segment at baseline, 95% CI: −2.1 to −3.9; p = 0.0004) (Figs. 1C and Figure 1D). Patients received antibiotics and nonsteroidal anti-inflammatory agents; beta-adrenergic blocking agents were given to 5 patients with LV systolic dysfunction. All patients showed clinical improvement during 2 to 3 (mean 2.4 ± 0.7) days of hospitalization and had complete resolution of clinical symptoms at follow-up. This report is limited by the fact that T2-weighted CMR imaging was not performed.

This article was published in JACC Journals and referenced in Family Medicine & Medical Science Research

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