PMC6884985_01
A 78-year-old female presenting with fatigue who was diagnosed with acute myelogenous leukemia M2 and treated with idarubicin and cytarabine. (a) Axial contrast-enhanced computed tomography (CT) image obtained 3 weeks following initiation of anthracycline therapy. The patient complained of dyspnea at this time. No abnormalities were detected. There was no pulmonary embolus. The lungs were clear and the myocardium appeared unremarkable. (b and c) Axial non-contrasted CT images obtained 18 weeks after the anthracycline induction chemotherapy. At this time, the patient had fatigue but no other symptoms. Diffuse hyperdensity is noted within the myocardium compatible with calcifications (arrows). This was new compared to the prior CT.
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F1
Of note, the myocardium had a normal appearance on this CT examination [Figure 1a]. At 18- week post-anthracycline initiation, a CT thorax without IV contrast was ordered as part of the pre-transplant evaluation [Figure 1b and c].
A 78-year-old female presenting with fatigue who was diagnosed with acute myelogenous leukemia M2 and treated with idarubicin and cytarabine. A cardiac magnetic resonance imaging cardiovascular magnetic resonance (CMR) was ordered for further evaluation of myocardial calcifications seen on the non-contrasted computed tomography. (a) Balanced short axis steady-state free precession CMR demonstrated normal left ventricular (LV) size, function, and wall thickness. (b and c) T2 spectral attenuated inversion recovery CMR short axis (b) and axial (c) images demonstrate hyperintensity of the myocardium greatest at the septum, anterior, and lateral walls (arrows). Quantitative T2 signal ratios confirmed that T2-weighted myocardium signal was >1.9x than that of the skeletal muscle signal within the same sequence. (d-e) Delayed viability phase-sensitive inversion recovery (PSIR) segmented short axis (d) and 2-chamber views (e) demonstrate moderate irregular subepicardial enhancement (arrows). (f) Mid-left ventricular short axis pre-contrast native T1 map demonstrates increased T1 relaxation time in the corresponding regions of late gadolinium enhancement (green circle denoted by the arrow). Qualitatively, the region of interest appears higher on the color map compared to the remaining myocardium (more red colored than yellow). An increased T1 relaxation time of 1293 ms is noted within the green region of interest.
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F2
On CMR evaluation, cine balanced steady-state free precession CMR images demonstrated a normal wall thickness, a left ventricle size that was within normal limits, and normal left ventricular (LV) function [Figure 2a]. The dark blood T2 spectral attenuated inversion recovery images demonstrated hyperintensity of the myocardium most prominently anteriorly, laterally, and of the septal wall [Figure 2b and c]. Delayed imaging demonstrated moderate, irregular, subepicardial enhancement [Figure 2d-e]. T1 map of the mid-left ventricle demonstrated an increased T1 relaxation time which corresponded to the regions of late gadolinium enhancement (LGE) [Figure 2f]. The regions of myocardial calcification on the CT appeared more diffuse compared to the regions of abnormal LGE on the CMR; this suggested that myocarditis was not the only contributing factor for the calcifications.