Lymphocytic myocarditis

Case contributed by Dr Azza Elgendy


66 years old female presented with progressive shortness of breath and syncopal attack for 30 days.

Patient Data

Age: 66 years
Gender: Female

Generalized hypokinsia on cine 4CH images.  Cardiomegaly with biatrial enlargement. Abnormal hyperintense signals involving the myocardium on T2 DIR, as compared to the skeletal muscle, the ratio is 3:1 . Early enhancement when comparedT1 DIR pre to post contrast. Patchy mid myocardial LGE associated with subepicardial enhancement. 

Annotated image

Both images show illustration of the enhancement pattern seen with the myocarditis. This includes patchy mid myocardial as well as sub-epicardial . 

Case Discussion

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. 

Gross Description:  

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.

Microscopic Description:  

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.  

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