When a “flu” turns into a cardiac transplant – case report

Abstract

Introduction. Based on the European Society of Cardiology statement1, dilated cardiomyopathy (DCM) is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to cause global systolic impairment. Among the non-familial causes, myocarditis is one of the most common and is implicated in 9-16% of adult patients with unexplained non-ischaemic DCM. We present a case of a 21 year-old patient who presented with a DCM few days after a flu. Case Presentation. A 21 year-old male was admitted at the emergency room (ER) with flu-like symptoms. He complained of cough, fever and tiredness. He was a healthy subject with irrelevant medical history and no ambulatory medication. Physical examination didn't show relevant findings. A blood panel was requested and revealed significantly elevated transaminases without any other major finding. He was purposed to further investigation but refused and went home with symptomatic treatment. A few days later, he returned to the ER complaining of extreme tiredness. He was confused and with signs of hypoperfusion. A transthoracic echocardiogram (TTE) revealed a DCM. During the observation he suffered a cardiac arrest. He was promptly resuscitated and transferred for an intensive care unit. TTE revealed severely depressed cardiac function (LVEF ~5%; Figure 1), severe dilation of all four chambers and left ventricle spontaneous echo contrast (figure 2). Myocardial biopsy wasn't performed because of the extremely thin ventricular walls. VAECMO and intra-aortic balloon pump were initiated for circulatory support. At this time his name was already in the national organ transplant waiting list and he was transferred to our Centre. Decision was to place a left ventricular assist device as a bridge to cardiac transplant (figure 3, 4). Twenty five days later, he had his cardiac transplant with no intercurrences. On tenth postoperative day he was transferred to general ward, where he's still recovering. We're still waiting for the heart histological result. Conclusion. DCM is a condition with variable clinical course, often requiring ventricular assist devices or even cardiac transplant. Endomyocardial biopsy is essential to define myocarditis as the cause of DCM. In this case, with the epidemiological context and exclusion of other possible causes, we believe this is a DCM secondary to myocarditis.