PMC9553720_01
(a, b) Electrocardiogram (50 mm/s) showing low-voltage morphology, tachycardic sinus rhythm (103 bpm), and repolarization abnormalities.
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The first assessment showed an afebrile patient (36.5 C) with sinus tachycardia (108 bpm), hypertension (153/110 mmHg), respiratory rate 15/min, SpO2 87% on room air, signs of low voltage in ECG (Figures 1(a) and 1(b)), anasarca, ascites, pleura effusion, and a massive pericardial effusion on ultrasound evaluation.
Initial transthoracic echocardiography indicating pericardial tamponade. (a) Apical 4-chamber view with large circumferential pericardial effusion. (b) Apical 4-chamber view (M-mode) with 4.89 mm pericardial effusion end diastolic. (c) Mitral inflow respiratory variation > 25% and (d) tricuspid inflow respiratory variation > 40% by PW-Doppler indicating tamponade morphology; scale and velocity settings are not optimal due to intensive care unit bedside echocardiography.
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Dedicated echocardiography (supplemental files, video 1) revealed reduced left and right ventricular function, collapse of the left and right atrium, and a massive circumferential pericardial effusion (48.9 mm apical) suggesting echocardiographic tamponade (Figure 2).
Cross-sectional studies confirmed myocardial inflammation. (a-d) Cardiac magnetic resonance imaging showing right ventricular hypertrophy (a, SSFP cine, *), increased T1 relaxation time (septal: 1062 ms, LV posterior wall: 1118 ms) and ECV of 33% (b, T1 map), increased T2 relaxation time to 52 ms septal and 60 ms in LV posterior wall (c, T2 map) and right ventricular, diffuse septal and left ventricular posterior wall late gadolinium enhancement (c, PSIR LGE, arrows) indicating myocarditis and diffuse biventricular fibrosis. (e, f) Positron emission tomography with computed tomography showing FDG uptake in the right ventricular myocardium (SUVmax 5.3), left ventricular uptake was within normal limits.
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Cross-sectional studies (Figure 3) confirmed myocardial inflammation indicating myocarditis with diffuse biventricular fibrosis.