Letter to the Editor Viral myocarditis masquerading acute coronary syndrome (ACS) – MRI to the rescue Abdul Hakeem a, ⁎ , Sabha Bhatti a , Annie Fuh b , Mary Mallof a , Charles Stone b,c , Francis Thornton c , Su Min Chang b a Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, WI, USA b Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin Hospital and Clinics, Madison, WI, USA c Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, WI, USA Received 5 January 2007; accepted 1 April 2007 Available online 25 May 2007 Abstract A young man with a strong family history of myocardial infarction with sudden death presented with chest pain and was found to have positive cardiac biomarkers and echocardiographic evidence of inferolateral wall hypokinesia. He was managed as an acute coronary syndrome and underwent a thorough ischemic work-up which was negative. Subsequently, a cardiac MRI was performed that demonstrated a patchy subepicardial enhancement, most consistent with acute viral myocarditis. This case demonstrates the importance of cardiac MRI in distinguishing an acute coronary syndrome from viral myocarditis. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac MRI; Viral myocarditis; Clinical decision making 1. Case summary A 24-year-old male, whose father died of a myocardial infarction (MI) at the age of 32, presented to the emergency room (ER) with chest pressure associated with dyspnea and diaphoresis. Two days prior to admission, he had flu-like symptoms including diarrhea and generalized fatigue. He denied use of cocaine or other illicit drugs. Physical exam on presentation showed a BP of 119/74, temperature of 97.8 °F and a heart rate of 70 bpm. His jugular venous pressure was normal. First and second heart sounds were normal without any audible murmurs, rubs or gallops. Chest was clear to auscultation. Initial labs demonstrated a white blood cell count of 8600/mm 3 ; sedimentation rate of 15 mm/h; creatine kinase (CK) of 682 U/l; CK-MB of 34.6 ng/ml; troponin I of 10 ng/ml (normal range: 0–0.3 ng/ml). Urine drug screen was negative. Electrocardiogram revealed normal sinus rhythm, with normal axis and no ST-T changes. Chest radiograph showed a normal cardiothoracic ratio. The patient was given aspirin, intravenous beta-blockers, nitroglycerin paste and a heparin drip in the ER. Transthoracic echocardiography in the ER demonstrated severe akinesia of the inferior and posterior wall and impaired left ventricular (LV) systolic function with an ejection fraction (EF) of 50%. Based on the clinical and strong family history, positive troponins and infero-posterior akinesia demonstrated on echo, the patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI) and epitifibatide was hence started. The patient subsequently underwent coronary angiography which demonstrated normal coronary anatomy with a right dominant system. There was no significant coronary occlusive disease except some minor luminal irregularities. Left ventri- culogram demonstrated mild akinesia of the inferobasilar wall. A transthoracic echocardiogram with bubble study perfor- med the next day demonstrated an EF of 50% and an “infarct” involving the inferior and posterior walls manifested by wall motion abnormality. There was also a moderate right-to-left (R–L) shunt during Valsalva with agitated saline through a patent foramen ovale (PFO). Based on the R–L shunt due to International Journal of Cardiology 119 (2007) e74 – e76 www.elsevier.com/locate/ijcard ⁎ Corresponding author. Tel.: +1 608 695 3048; fax: +1 608 262 6743. E-mail address: a.hakeem@hosp.wisc.edu (A. Hakeem). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.04.006