The findings suggest myocarditis, 2 criteria of Lake Louise consensus, includes T2 myocardium to skeletal muscle signal ratio > 1.9 and delayed myocardial enhancement including sub-epicardial and mid myocardium. The course of the disease was so aggressive that the patient passed away few weeks after the exam.
The specimen is received on saline soaked gauze in a container labeled with the patient's name and "myocardial biopsy x6" and consists of six fragments of tan-pink soft tissues ranging from 0.1-0.25 cm in greatest dimension. The specimen is submitted in toto in one cassette. Please note some of the tissues may not survive processing.
Histologic evaluation reveals fragments of myocardium with chronic inflammation including lymphocytes and rare eosinophils. Rare giant cells are present. A Congo red stain is negative for amyloid. Fragments of myocardium are moderately fibrotic and contain a patchy moderately dense chronic inflammatory cell infiltrate comprised predominantly of lymphocytes with a few plasma cells and an occasional eosinophil.