PMC8133866_01
EKG performed in the ED showed a heart rate of 74 and a regular sinus rhythm, with no acute disease processes.
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fig1
His initial ECG showed no acute changes (Figure 1), and a bedside echocardiogram showed a preserved ejection fraction.
Bone marrow aspirate smears were significant for approximately 62% myeloblasts, and the background hematopoiesis was markedly decreased.
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fig2
Bone marrow aspirate smear is shown in Figure 2.
Cardiac MRI showed features consistent with myocarditis satisfying the updated Lake Louise criteria, visualized in these images. (a) Mid-short-axis native T1 mapping demonstrated elevated native myocardial T1 at 1173 ms (local lab normal reference: 950-1050 ms). (b) Mid-short-axis T2 mapping demonstrated elevated myocardial T2 at 58 ms (normal reference: 40-50 ms). (c) Mid-short-axis phase-sensitive inversion recovery late gadolinium enhancement image showed multiple areas of subepicardial enhancement in the lateral wall, as well as midmyocardial enhancement in the septum. (d) Four-chamber late gadolinium enhancement image demonstrated midmyocardial enhancement in the septum and subepicardial to midmyocardial enhancement in the lateral wall.
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fig3
A dedicated cardiac MRI (Figure 3) demonstrated evidence of nonischaemic myocardial inflammation consistent with myocarditis.
Skin biopsy showed dense dermal infiltrate of polymorphonuclear cells at both low (a) and high (b) magnification.
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fig4
The histologic image of the skin biopsy at both low and high magnification is shown in Figure 4.