PMC4008442_01
First-pass perfusion images. Subendocardial perfusion defects seen on these first-pass perfusion images in the initial exam when patient was critically ill (a) do not conform to any coronary distribution and have improved in the study done in seven weeks on cyclosporine and prednisone (b), and show stabilization from then on as evidenced on the study done in nine months (c).
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fig1
First-pass perfusion demonstrated nonspecific subtle subendocardial hypoperfusion defect, not following any coronary distribution (Figure 1). The first-pass perfusion imaging showed hypoperfused subendocardial defects remained generalized (Figure 1). First-pass perfusion by gadolinium revealed an unchanged generalized subendocardial, near circumferential hypoperfusion defect (Figure 1).
Delayed gadolinium hyperenhancement images. DHE-CMR pattern of patchy delayed hyperenhancement secondary to giant cell myocarditis or a severe form of cardiac sarcoidosis. Patchy hyperenhancement in left ventricular wall and diffuse enhancement in right ventricular wall in the initial exam (a1, a2, and a3) has improved to coalescence of hyperenhancement in seven weeks on cyclosporine and prednisone (b1, b2, and b3). The nine-month exam (c1, c2, and c3) shows a stabilization of change in hyperenhancement as compared to the seven-week exam.
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fig2
Late imaging after the postedema washout period reveals a marked patchy signal consistent with a severe inflammatory or infiltrative process (Figure 2). DHE showed moderate improvement and coalescence of previously seen LV myocardial enhancement with mild to moderate improvement in RV signal as well (Figure 2). The DHE pattern had mildly improved as well (Figure 2).
Hematoxylin and Eosin staining of myocardial biopsy specimen at 100x resolution demonstrating well-formed granuloma (black arrow) and myocardial fascicles (white arrow).
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fig3
The EMB showed noncaseating granulomatous inflammation with many multinucleated giant cells, histiocytes, and mild chronic inflammation (Figures 3 and 4).
Hematoxylin and Eosin staining of myocardial biopsy specimen at 200x resolution demonstrating well-formed granuloma (black arrow) with a multinucleated giant cell in the center (white arrow).
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fig4
The EMB showed noncaseating granulomatous inflammation with many multinucleated giant cells, histiocytes, and mild chronic inflammation (Figures 3 and 4).