CONGRESS ABSTRACT

Introduction Myocarditis is an inflammatory process of the myocardium that can present with highly variable clinical manifestations; often myocarditis presents with the typical signs of acute myocardial infarction with no coronary arteries lesions on angiographic examination. The initial differential diagnosis is sometimes difficult, so it is always necessary to consider a possible myocarditis. Below we present a clinical case in which magnetic resonance (CMR) was essential for the correct diagnosis. Case Report A young patient of 50 years, obese, diabetic, smoker, hypertensive and dyslipidemic, without important co-pathologies, comes to our ED for oppressive retrosternal chest pain, irradiated to the upper limbs, worsened by supine decubitus and improved by standing. Chest X-ray and ECG were normal. Serial troponines were around 3500-3900 ng/L with CK-MB > 150 ng/ml. Admitted to our department, there was a recurrence of pain with a normal ECG. The patient had also fever and reported flu-like syndrome the previous week. PCR and white blood cells were high with an increasing trend. The echocardiogram (ECD) showed normal global and segmental left ventricular function. Thinking to myocarditis, therapy with ASA 1 g TID was started with excellent control of chest pain. CMR documented outcomes of non-reperfused ischemic necrosis of the posterolateral wall of the left ventricle extending to the apical segments (16% of the myocardial mass). The therapy was modified in an anti-ischemic sense and the coroangiographic examination highlighted: critical stenosis of the middle IVA and occlusion of OM1 treated with PTCA and DES implantation. The subsequent course was regular and the patient was discharged without complications. The recent anamnesis, the persistently normal ECG, the normal ECD and the high inflammation labs, together with the enzymatic release had led us to diagnose and start the specific treatment of myocarditis. The CMR, however, highlighted a significant ischemic lesion that was substantially "silent" from the basic instrumental point of view. In this case, the infarction presented itself with the characteristics of myocarditis (probably inflammation process caused by ischaemia), instead of the more frequent opposite situation. The broad symptomatic spectrum and the various possible clinical/instrumental manifestations in these patients must always lead us to a rapid and accurate differential diagnosis. Magnetic resonance imaging proved to be decisive.