Letters to the Editor Segmental myocardial hypokinesis and hypertrophy as initial echocardiographic presentation of myocarditis ☆ Eleftherios Tsiamis, Vasiliki Panagopoulou, Constantina Aggeli, Konstantinos Toutouzas, Evangelos Oikonomou, Christodoulos Stefanadis, Dimitris Tousoulis ⁎ 1st Department of Cardiology, ‘Hippokration’ Hospital, University of Athens Medical School, Athens, Greece article info Article history: Received 8 August 2014 Accepted 9 August 2014 Available online 27 August 2014 Keywords: Cardiac magnetic resonance Echocardiography Hypertrophy Hypokinesis Myocardial strain Myocarditis We present an interesting myocarditis case in which the diagnosis was suspected at first sight by clinical presentation, electrocardiograph- ic abnormalities and transthoracic echocardiogram. Patient was a 17 year old male, athlete, with no past medical history, who was admit- ted to our Cardiology Department complaining of fever, chest pain and dyspnea over the preceding 4 days. His body temperature was 38 °C, blood pressure was 105/70 mm Hg and his heart rate was 114 bpm. Lab- oratory studies demonstrated high WBC: 13.35 × 10 3 /μL; PMN: 80.2%; lymphocyte: 11.2%; SGOT: 105 IU/L; SGPT: 82 IU/L; LDH: 430 U/L; CPK total: 515 U/L; troponin I: 27.45 ng/mL; B type natriuretic peptide: 720.90 pg/mL and C reactive protein: 343.5 mg/L. Electrocardiogram showed sinus tachycardia (106 bpm), ST segment elevation in leads II, III, aVF, V2, and V3, and T wave inversion in leads V4, V5, and V6. Trans- thoracic echocardiogram demonstrated left ventricular dilation with myocardial hypertrophy most prominent in the inferolateral wall with significantly increased echogenicity indicating myocardial edema. Ejec- tion fraction (EF) of the left ventricle was significantly depressed (EF = 25%) and a small pericardial effusion was present locally in the inferolateral wall (Supplemental Video 1). Systolic function of right ventricle was also depressed (Tricuspid Annular Plane Systolic Excur- sion—TAPSE = 14 mm) (Supplemental Video 2). Speckle tracking echo- cardiography of the left ventricle was performed at that phase demonstrating that longitudinal and circumferential strains were signif- icantly compromised (-9%, -16% respectively) (Fig. 1, panel A) especially in the most hypokinetic segments. Left heart catheteriza- tion showed normal coronary anatomy without atherosclerotic lesions. Patient underwent cardiac magnetic resonance (CMR) with gadolinium administration. Cine images demonstrated a dilated left ventricle with globally depressed EF and small pericardial effusion. Hypertrophy of the left ventricle due to edema was observed in T2 weighted CMR im- ages. There were also evidences of acute myocardial inflammation with late gadolinium enhancement in the epicardial layer of lateral, inferolateral wall and in the apex (Fig. 1, panel B). The patient was on β-adrenergic blocker (metoprolol 100 mg 1/4 × 2) and angiotensin converting enzyme inhibitor (captopril 25 mg 1/4 × 3) treatment. At the follow-up (two months after hospital discharge) the patient was asymptomatic. Impressively, at the follow-up transthoracic echocardio- gram and CMR, left ventricular dilation and hypertrophy had almost re- solved with a significant improvement of ejection fraction and edema recession (Fig. 1, panel C and Supplemental Videos 3 and 4). A signifi- cant improvement of the longitudinal and circumferential strain was also observed (Fig. 1, panel D). Myocarditis has a wide variation on the clinical presentation among patients. ECG findings and serological markers of myocardial necrosis are non-specific for the disease and have low sensitivity for detecting myocarditis [1,2]. The most widely used non-invasive imaging techniques for diagnos- ing myocarditis are echocardiography which is recommended for the initial diagnostic evaluation of all patients with suspected myocarditis [3] and contrast enhanced CMR which provides diagnostic information regarding the inflammatory process in myocardium. There have been proposed CMR criteria (“Lake Louise criteria”) which require the presence of at least 2 out of 3 findings (hyperemia, edema, necrosis/scar) for establishing the diagnosis of active myocarditis [4]. This case points out the importance of cardiac imaging-both echocardiography and CMR- in the diagnosis of acute myocarditis. Echocardiography demonstrated indi- rectly edema through hypertrophy of the left ventricle, in the early stages of the disease, confirmed later by CMR, which established the diagnosis. Both cardiac imaging techniques depicted impressively the almost com- plete restoration of left ventricular function at follow-up, 2 months after hospital discharge. International Journal of Cardiology 176 (2014) 1460–1461 ☆ Sources of funding: none declared. ⁎ Corresponding author at: Vasilissis Sofias 114, TK 115 28, Hippokration Hospital, Athens, Greece. Tel.: +30 213 2088099; fax: +30 213 2088676. E-mail address: drtousoulis@hotmail.com (D. Tousoulis). http://dx.doi.org/10.1016/j.ijcard.2014.08.064 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard