PMC8727758_01
Skin lesions at presentation. (A) 1 x 1 cm sized erythematous to black colored ulcerative lesion covered with crust was observed on his scrotum. (B,C) Diffuse maculopapular rash on the trunk and back.
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F1
On the initial physical examination at the emergency department, a fine inspiratory crackle was heard on both lungs, and an asymptomatic 1 x 1 cm sized erythematous to black-colored ulcerative lesion covered with crust was observed on his scrotum (Figure 1A). There was also a diffuse maculopapular rash on his trunk (Figure 1B) and back (Figure 1C). Because his ECG showed slight ST-segment depression on the V5-V6 (Supplementary Figure 1A) and troponin T was elevated up to 0.231 ng/ml (reference value < 0.005 ng/ml), echocardiography was performed, and it showed focal hypokinesis in basal, basoinferior, and mid to basal inferolateral segments with mild left ventricular (LV) systolic dysfunction with 45% of ejection fraction (EF) with normal LV wall thickness (Figure 3A, Supplementary Videos 1, 2). Although summer is not the peak season of scrub typhus in Korea and the result of the initial antibody for O. tsutsugamushi was negative, the clinical diagnosis of scrub typhus was made based on eschar, typical skin rash (Figures 1A-C), and history of outdoor activity. Figure 1B). Follow-up echocardiography showed global hypokinesis with aggravated LV systolic function (EF = 37%) with normal LV and RV wall thickness (Figure 3B, Supplementary Videos 3, 4).
Summary of disease course. Major events and therapeutics are summarized in the figure. BSI, Bloodstream infection; ECMO, Extracorporeal membrane oxygenation; EMB, endomyocardial biopsy.
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F2
Because his ECG showed slight ST-segment depression on the V5-V6 (Supplementary Figure 1A) and troponin T was elevated up to 0.231 ng/ml (reference value < 0.005 ng/ml), echocardiography was performed, and it showed focal hypokinesis in basal, basoinferior, and mid to basal inferolateral segments with mild left ventricular (LV) systolic dysfunction with 45% of ejection fraction (EF) with normal LV wall thickness (Figure 3A, Supplementary Videos 1, 2). Administration of intravenous (IV) azithromycin was started (500 mg every 24 h) and information about major events and treatments during the clinical course is summarized in Figure 2.
Echocardiography. (A) Echocardiography at presentation showed normal left ventricular (LV) wall thickness and chamber size. (B) Echocardiography 6 h before cardiac arrest showed normal LV wall thickness. (C) Echocardiography just after extracorporeal CPR showed thickened LV (13.6 mm, posterior wall, 11.8 mm septum) and right ventricle wall.
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F3
Because his ECG showed slight ST-segment depression on the V5-V6 (Supplementary Figure 1A) and troponin T was elevated up to 0.231 ng/ml (reference value < 0.005 ng/ml), echocardiography was performed, and it showed focal hypokinesis in basal, basoinferior, and mid to basal inferolateral segments with mild left ventricular (LV) systolic dysfunction with 45% of ejection fraction (EF) with normal LV wall thickness (Figure 3A, Supplementary Videos 1, 2). Figure 1B). Follow-up echocardiography showed global hypokinesis with aggravated LV systolic function (EF = 37%) with normal LV and RV wall thickness (Figure 3B, Supplementary Videos 3, 4). Echocardiography performed just after ECMO pump on showed markedly thickened up to about 13 mm (Figure 3C, Supplementary Video 5) both ventricular wall with newly formed mild to moderate pericardial effusion without features of cardiac tamponade.
Endomyocardial biopsy. Inflammatory cell infiltration consisting of T-lymphocyte within interstitium and myocardium (A-X40, Hematoxylin-Eosin) (B-X200, Hematoxylin-Eosin), with an indication of lymphocyte (black arrow).
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F4
Figure 1B). Follow-up echocardiography showed global hypokinesis with aggravated LV systolic function (EF = 37%) with normal LV and RV wall thickness (Figure 3B, Supplementary Videos 3, 4). Endomyocardial biopsy showed lymphocytic infiltration in myocardium and interstitium which is compatible with myocarditis with T-lymphocytic infiltration (Figures 4A,B) with positive staining for CD3 and CD5 and negative for CD 20.