Introduction: Viral myocarditis is a rare and potentially lethal manifestation of Epstein-Barr Virus (EBV). Care for these patients is individualized as EBV can present with a variety of cardiac manifestations. Due to its variable presentation and difficulties with diagnosis, there is lack of standardized recommendations for management. The use of steroids in the treatment of EBV-induced myocarditis is controversial. The following is a case report of fulminant EBV myocarditis successfully treated with mechanical circulatory support and high-dose steroid therapy.
Description: A 41 year old female with no past medical history presented to an emergency department with 3 days of nausea, vomiting, diarrhea, and intermittent fevers. Her workup was notable for electrocardiogram (EKG) changes highly concerning for a myocardial infarction. She was taken emergently for cardiac catheterization where she was found to have a normal coronary angiogram but impressively depressed cardiac output. Her clinical status worsened to cardiogenic shock necessitating inotropic support and transfer to a tertiary care center where she received emergent right heart catheterization with temporary ventricular assist device (VAD) implantation. During the procedure her shock continued to worsen so she was taken to the operating room for emergent venous-arterial (VA) extracorporeal membrane oxygenation (ECMO) cannulation. Workup for her non-ischemic cardiomyopathy included serologies and an endomyocardial biopsy consistent with EBV-induced myocarditis. High-dose steroid therapy was started while she was maintained on mechanical circulatory support. She was progressively decannulated from VA ECMO, weaned from her VAD, and discharged on day 11 of hospitalization.
Discussion: Fulminant myocarditis, when unrecognized, can lead to significant morbidity and mortality. The following case report highlights the importance of early recognition and prompt escalation to mechanical circulatory support for successful treatment. Although the role of steroids in infectious myocarditis remains controversial, this case suggests that high-dose steroids can be administered safely in select patients with EBV-induced myocarditis and potentially prove beneficial as an adjunctive therapy.
