Acute infectious-allergic myocarditis

Patient I. 68 years old.

Complaints.

He was admitted to the intensive care unit of Medicina JSC on 03/15/2017 with complaints of palpitations of up to 120-130 per minute, shortness of breath with minimal physical activity, weakness, edema of the lower extremities.

Medical history.

· In childhood, suffered from rheumatism.

· For a long time noted an increase in blood pressure, up to a maximum of 170/100 mm Hg. Art. Adapted to 130/80 mm Hg. Art.

· Denies previous myocardial infarction.

Deterioration of the condition since the end of January 2016, when, against the background of the postponed ARVI, he began to notice an increase in shortness of breath, weakness

· Since the beginning of February he took cycloferon.

On February 13, 2016, due to the continuing deterioration, he applied to JSC "Medicine". A CT scan of the chest organs was performed: CT scan of bilateral polysegmental bronchopneumonia. Mediastinal lymphadenopathy. Calcifications in s10 of the right lung. Bulla in the middle lobe of the right lung.

A course of intravenous drip infusion of Rocefin 2 g was carried out. No. 10, against which he noted an improvement in his condition. Since the end of February he has been taking Ingavirin.

Another deterioration from the beginning of March 2016 - shortness of breath increased again, palpitations of up to 120-130 per minute and edema of the lower extremities appeared.

During examination at JSC "Medicine" 03/15/2016

ECG - tachysystolic form of atrial fibrillation, diffuse changes in the left ventricular myocardium.

Echocardiography - moderate left ventricular hypertrophy, dilatation of all cardiac cavities, significant pulmonary hypertension up to 70 mm Hg. Art., reducing the ejection fraction up to 46%.

CT of the chest organs is a CT picture of the positive dynamics of bilateral polysegmental bronchopneumonia. Mediastinal lymphadenopathy. There is a negative trend in the form of effusion in the pleural cavities. The CT picture corresponds to interstitial pulmonary edema. Aortocoronarosclerosis.

Due to the deterioration of his condition on 03/15/2017, he was hospitalized in the intensive care unit of JSC "Medicine".

Status Praesens .

· Condition on admission of moderate severity.

· Skin: pale, warm, dry. Visible mucous membranes: pale, clean, moist, shiny. Musculoskeletal system without visible pathology. Lymph nodes were normal. Swelling of the feet, legs.

· Free breathing through the nose. Respiration rate 18 in 1 min. The rib cage is cylindrical in shape, evenly participates in the act of breathing. Painless on palpation. When percussed, pulmonary sound over the entire surface of the lungs. The boundaries of the lungs are not changed. On auscultation: hard breathing, weakened in the lower parts on both sides, against this background, non-voiced moist fine-bubbling rales are heard.

· There is no pathological pulsation in the region of the heart, vessels of the neck and epigastrium. On auscultation, heart sounds are muffled, the rhythm is abnormal, systolic murmur at the base of the heart. Pulse 128 beats. per minute, the rhythm is incorrect, satisfactory filling and tension.

CC = HR = 70 beats / min. BP 190/100 mm Hg. Art.

· Appetite is normal. The tongue is moist and clean. The abdomen of the correct shape, not swollen, participates in the act of breathing evenly. On palpation, it is soft, painless. Percussion-free fluid and gas in the abdominal cavity is not detected. Auscultatory peristalsis is heard. The liver protrudes 1 cm from under the costal arch. The edge of the liver on palpation is dull, elastic, painless. The spleen is not palpable.

· There are no dysuric disorders. The kidney area is not visually changed. The tapping symptom is negative on both sides.

Data of laboratory and instrumental research.

Clinical blood test - hypochromic, hyperregenerative anemia with a minimal decrease in hemoglobin up to 91 g / l, leukocytosis up to 12-13 g / l, lymphopenia up to 4%.

Secondary blood tests - C-RB 33-70-60, an increase in creatinine levels up to 158, troponin - 1.2-1.3-2.1 ng / ml with normalization over time, reverses an increase in the level of MV-CPK up to 29 -31 with subsequent normalization, with a normal level of total CPK, the level of electrolytes is normal.

D-dimer is positive.

PSA is normal. ASLO, RF unchanged. Serum iron levels are normal, a significant increase in ferritin up to 1936 (normal up to 400), a decrease in the level of TIBC. Pronounced increase in IgG titer to cytomegalovirus, moderate increase in AT titer to Epstein-Barr virus.

Since 03/17/2016, an increase was noted in the blood test: ALAT 608.1 U / l ASAT 560.8 U / l.

ECG - atrial fibrillation, normosystolic form.

The horizontal position of the electrical axis of the heart. Signs of left ventricular myocardial hypertrophy. Diffuse changes in the left ventricular myocardium (T is reduced in all leads).

Doppler ultrasonography of the veins of the lower extremities - no pathology of deep veins and perforating veins of the lower extremities was revealed.

At the time of examination, there were no signs of acute thrombosis of the veins of the lower extremities.

Ultrasound of the pleural cavities in the patient's sitting position along the scapular lines:

· On the left, the presence of free liquid is determined with an approximate volume of about 100 ml;

· On the right, the presence of free liquid is determined with an approximate volume of about 300-400 ml.

EchoCG from 03/16/2017 - in comparison with the echocardiogram from 03/15/2015, a decrease in systolic pressure in the pulmonary artery to 45 mm Hg. Art., a slight increase in total contractility - EF 48%.

Ultrasound - ultrasound signs of compaction of the CLS of both kidneys. Ultrasound signs of moderate diffuse changes in the liver, cholelithiasis, calculus and thickening of the walls of the gallbladder, diffuse changes in the pancreas.

Examined by a pulmonologist on March 16, 2016:

Out-of-hospital bilateral polysegmental bronchopneumonia, stage of reverse development;

· Mediastinal lymphadenopathy;

· Bilateral small hydrothorax.

It is recommended to continue Tavanic 500 mg / day.

Control of the clinical blood test, CRP after 72 hours from the first injection of the drug to assess its effectiveness and further correction. Control of the QT interval.

Conclusion of the consultation.

Taking into account the connection between the deterioration of well-being in the form of an increase in signs of heart failure with acute respiratory viral infections in January with a relapse of the clinical deterioration 2 weeks after "recovery" from acute respiratory viral infections in combination with diffuse changes in myocardial contractility according to ECG data, the diagnosis of infectious-allergic myocarditis was established.

Clinical diagnosis.

Acute infectious-allergic myocarditis.

Rhythm disturbance: first detected paroxysm of atrial fibrillation, of unknown age.

Pulmonary hypertension. Bilateral hydrothorax. Chronic heart failure stage II B.

Hypertension stage II, 3 degrees, risk 4. Left ventricular hypertrophy. Impaired glucose tolerance.

Community-acquired bilateral lower lobe polysegmental pneumonia, resolution stage. Respiratory failure of the 2nd degree. Initial manifestations of acute renal failure (glomerular filtration rate 38 ml / min.).

Medicinal hepatitis.

Mild hypochromic anemia.

Obesity I degree, alimentary-constitutional.

Treatment.

IV cordaron 50 mg per hour.

IV heparin 1 thousand units per hour under the control of APTT, followed by replacement with subcutaneous administration of clexane.

IV perlinganite in a standard dilution of 2 ml per hour (taking into account the phenomena of circulatory insufficiency in the pulmonary circulation, severe pulmonary hypertension).

IV prednisolone 90 mg per day.

IV lasix 40 mg hydrobalance.

Renitek 10 mg 1 tablet 2 times a day under the control of blood pressure.

Veroshpiron 50 mg per day.

IV tavanic 500 mg per day, followed by dose adjustment to 250 mg per day, taking into account the decrease in GFR.

Given the unknown age of paroxysm of atrial fibrillation, emergency cardioversion was not performed.

Against the background of complex therapy, an improvement in the condition was noted: edema of the lower extremities regressed, the severity of shortness of breath decreased, predominantly atrial fibrillation normosystole was achieved, blood pressure stabilized, and appetite improved.

There was a tendency towards an increase in the hemoglobin level to 99 g / l, a decrease in the level of C-reactive protein, positive laboratory dynamics of drug hepatitis, the level of creatinine did not increase.

At the request of relatives with a significant improvement on March 18, 2016, he was transferred to the N.V. Sklifosofsky.

Case features.

Infectious-allergic myocarditis was diagnosed in a timely manner in a patient with out-of-hospital polysegmental pneumonia. This contributed to the early appointment of adequate therapy and a significant improvement in the patient's condition.