PMC9851183_01
Skin lesions (A, B), chest x-ray (C) at admission and electrocardiogram at admission (D). At admission, the electrocardiogram revealed sinus rhythm with diffuse ST elevation with upward concavity in leads (I, II, III, AVF, V4, V5, and V6) and diffuse depressed PR segment.
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F1
Multiple coalescing ulcerations covered the right tonsil with a necrotic base and confluent lesions, which showed a necrotic center and white margins (Figure 1A). During his stay at the hospital, a small number of millimetric umbilicated pustules with an erythematous base on the trunk and the proximal region of the limbs also appeared (Figure 1B). The chest x-ray revealed no significant findings (Figure 1C). T wave in III, and a diffusely depressed PR segment (Figure 1D).
CMR images: the balanced FFE (fast field echo) sequences acquired along the short axis (A, B) and two chamber (C) and four chamber (D) views demonstrate myocardial late gadolinium enhancement with epicardial predominance in the lateral and inferior wall and mesocardial predominance in the septum and anterior wall (view arrows).
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F2
An increased myocardial and pericardial signal intensity on the T2 STIR sequence was suggestive of edema (Figure 2A). A color-coded image of T2 mapping (Figure 2B), native T1 (Figure 2C), and enhanced T1 mapping (Figure 2D) were also performed.
CMR images: (A) T2 STIR sequence: a high ratio (> 2) is seen in the intensity between the myocardium and the skeletal muscle compatible with a generalized edema. Color-coded image of T2 mapping in LV mid-chamber. The arrow marks an increased T2 value (T2 = 60 ms) in the lateral and inferolateral wall. (B) Color-coded image of T2 mapping in LV mid-chamber. The arrow marks an increased T2 value (T2 = 60 ms) in the lateral and inferolateral wall. (C, D) T1 mapping and T1 enhanced mapping, respectively. In T1 mapping, extensive area of increased T1 value (view pink and orange areas) in lateral and inferolateral walls. On quantitative analysis, values on the native T1 map were 1,160 ms (normal value 1,025-1,075 ms). In T1 enhanced mapping, these areas area correlated with increased extracellular volume (ECV).
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F3
Late gadolinium enhancement (LGE) images, obtained by using a balanced fast field echo (FFE) sequence, showed subepicardial and mesocardial enhancement of the myocardium and mild signs of pericarditis, which were considered consistent with acute myopericarditis (Figures 3A-D).
(A) Enlargement and coalescence of oral ulcerations on the tonsils and uvula 48 and 96 h after the diagnosis, respectively (B). (C) Electrocardiogram at discharge: Sinus rhythm without significant findings.
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F4
During his stay at the hospital, the previous electrocardiographic findings became normal (Figure 4A), whereas the oropharyngeal lesions increased in size and coalesced into large ulcerations located on both tonsils and the uvula (Figures 4B, C).