Myocarditis in an 18-Year-Old with Ulcerative Colitis

Abstract

CASE DESCRIPTION: An 18-year-old woman with recently-diagnosed ulcerative colitis (UC) on mesalamine presented with chest pain worsened by inspiration and exertion, dyspnea, and subjective fever for 6 hours. She had a self-limited dry cough 2 weeks prior. SARS-CoV-2 PCR was negative. At presentation, her hemoglobin was 7.1 g/dL. EKG showed sinus tachycardia. Peak troponin was 0.21 ng/mL. Transthoracic echocardiogram showed a possible mildly hypokinetic apex, and vasodilator stress test was normal. Due to persistent hematochezia and the possibility of mesalamine-induced myocarditis, mesalamine was changed to sulfasalazine for her UC. The patient was otherwise treated supportively and referred for outpatient cardiac MRI, but declined the study. Subsequently, Coxsackie B Virus Antibody Type 3 titer was strongly positive at > 1:640, confirming viral myocarditis. CONCLUSIONS: This case describes the work-up of an 18-year-old female patient with UC presenting with acute onset chest pain and fever. Differential diagnosis included viral myocarditis, mesalamine-induced myocarditis, pericarditis, pulmonary embolism, acute coronary syndrome (ACS), and multisystem inflammatory syndrome in children secondary to SARS-CoV-2. CLINICAL SIGNIFICANCE: Global incidence of viral myocarditis is 22 cases per 100,000 individuals annually; though significantly more common in males, female patients often present with more severe disease. Suspected myocarditis warrants an initial EKG and cardiac biomarkers followed by echocardiography, and when indicated, testing for ACS. While acute myocarditis is most commonly caused by coxsackievirus B3 and adenovirus in the U.S. and is treated supportively, several case reports of mesalamine-induced myocarditis prompted specific management for this patient with newly diagnosed UC. Thus, the acuity and incidence of myocarditis present a learning opportunity for differential diagnosis building and workup for young female patients with acute onset chest pain.