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Tania Elias, Ian Roberts, Nicola Jones, Nikant Sabharwal, Paul Leeson, Suppurative bacterial myocarditis: echocardiographic and pathological findings, European Heart Journal, Volume 29, Issue 4, February 2008, Page 489, https://doi.org/10.1093/eurheartj/ehm385
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A 45-year-old man was admitted with anorexia, weight loss, and rigors. Examination revealed a tachycardia (126 bpm), hypotension (86/50 mmHg), and a fever (39.5°C). He was cachectic with tattoos, piercings, and clinically dehydrated. Investigations revealed a normocytic anaemia (Hb 8.6 g/dL), neutrophilia of 11.31 × 109/L, and elevated C-reactive protein (>160 mg/L). Chest X-ray was normal. ECG revealed a broadened QRS complex and non-specific inferolateral T wave inversion (Panel A). Intravenous fluid and co-amoxiclav were commenced but the patient rapidly developed severe pulmonary oedema. Echocardiography demonstrated global severely impaired left ventricular systolic function with unusual thickening of the papillary muscles (Panels D–F). The patient initially improved with CPAP, diuretics, and antibiotics, but 12 h later developed pulseless ventricular tachycardia (Panel A) from which it was impossible to resuscitate him. Post-mortem revealed microabscesses containing gram-positive cocci (Panel C) throughout the left ventricular myocardium with confluent collections in the lateral wall and both inferomedial and anterolateral papillary muscles (Panel B, arrows). The rest of the heart, including valves and endocardium, and other organs were normal. Non-paravalvular bacterial myocardial abscesses are rarely diagnosed ante-mortem. They are thought to occur following bacteraemia and to be more common in the immunocompromised. Staphylococcus aureus is the most frequently isolated bacterium and death is usually due to intractable dysrhythmias, cardiac failure, tamponade, or fistulae. Diagnosis is dependent on a high clinical suspicion in septic patients with severe heart failure. Imaging and ECG changes are usually non-specific. However, in this case, transthoracic echocardiography demonstrated abnormalities consistent with the post-mortem findings.
