Mimicking ST-segment elevation myocardial infarction upon presentation, acute nonrheumatic streptococcal myocarditis is a treatable etiology of myocarditis which has only been infrequently reported.
Patients were identified through a retrospective query of electronic medical records over a 17-year period (January 1994 to December 2010). We describe a case series of acute nonrheumatic streptococcal myocarditis complicating pharyngitis in young adults.
Nine patients were identified; 89% were male, patients had an average age of 28.6 years, and 56% and 22% had confirmed group A and group G streptococcus, respectively. Latency from pharyngitis to chest pain averaged 3.1±1.1 days. No patients met the revised Jones criteria for acute rheumatic fever. All 9 patients (100%) presented with ST-segment elevations on electrocardiography and elevated cardiac biomarkers. Average peak creatine kinase was 934 U/L (normal<400 U/L), creatine kinase-MB was 82 ng/mL (normal<6.9 ng/mL), and troponin T was 2.30 ng/mL (normal<0.03 ng/mL). Six patients underwent coronary angiography, which revealed no obstructive culprit lesions. Cardiac magnetic resonance imaging confirmed myocarditis in 3 patients and was used to document resolution in follow-up for 2 patients. All patients had a complete clinical recovery.
Acute nonrheumatic streptococcal myocarditis is an under-recognized and treatable cause of ST-segment elevation and chest pain in young adults with a history of recent pharyngitis. Etiopathology extends beyond Lancefield group A streptococcus and includes group G streptococcal infection. Cardiac magnetic resonance may be useful in confirming the diagnosis and documenting the resolution.
"In this case, myocarditis occurs 2 to 4 weeks after the bacterial infection. In contrast, several cases indicate myocarditis occurred during or a few days after the streptococcal infection [6–8]. As mentioned above, this entity first described by Gore and Saphir in 1947 has been called nonrheumatic myocarditis . "
[Show abstract][Hide abstract] ABSTRACT: Myocarditis consists of an inflammation of the cardiac muscle, definitively diagnosed by endomyocardial biopsy. The causal agents are primarily infectious: in developed countries, viruses appear to be the main cause, whereas in developing countries rheumatic carditis, Chagas disease, and HIV are frequent causes. Furthermore, myocarditis can be indirectly induced by an infectious agent and occurs following a latency period during which antibodies are created. Typically, myocarditis observed in rheumatic fever related to group A streptococcal (GAS) infection occurs after 2- to 3-week period of latency. In other instances, myocarditis can occur within few days following a streptococcal infection; thus, it does not fit the criteria for rheumatic fever. Myocarditis classically presents as acute heart failure, and can also be manifested by tachyarrhythmia or chest pain. Likewise, GAS-related myocarditis reportedly mimics myocardial infarction (MI) with typical chest pain, electrocardiograph changes, and troponin elevation. Here we describe a case of recurrent myocarditis, 5 years apart, with clinical presentation imitating an acute MI in an otherwise healthy 37-year-old man. Both episodes occurred 3 days after GAS pharyngitis and resolved quickly following medical treatment.
[Show abstract][Hide abstract] ABSTRACT: Learning Objectives:
1. Diagnose acute streptococcal infection in the setting of a negative rapid strep test
2. Recognize that streptococcal infection can be complicated by myopericarditis which may mimic acute coronary syndrome (ACS)
A 20-year old African-American male with past medical history of hypertension and asthma presented with severe chest pain described as “the grim reaper sticking his scythe in my chest” in the setting of a several day history of sore throat, fever, chills, myalgias, and back pain. He denied a cough. His temperature was 100°F, and he was hypertensive (160/93), tachycardic (120 beats/min), and tachypneic (24 breaths/min) with an O2 saturation of 99% on room air. On exam, he was diaphoretic and had dry mucous membranes, tender anterior cervical lymphadenopathy, and erythema of the oropharynx. Initial labs were remarkable for white blood cell count of 24,600 cells/µL, with ESR of 77 mm/hr and CRP of 30.2 mg/dL. His troponin on presentation was 0.487 ng/mL. Monospot, HIV, and rapid strep screening tests were all negative. Imaging included a normal chest X-ray. His initial EKG was normal. On hospital day #2, he again complained of severe chest pain, and a repeat EKG showed ST elevation in leads I, II, aVL, and V4-V6. His troponin peaked at 2.69 ng/mL, with total CK of 2,641 u/L and CKMB of 2.2 ng/mL. A transthoracic echocardiogram showed a normal ejection fraction and no wall motion abnormalities. A cardiac catheterization was performed, which revealed no obstructive culprit lesions. Treatment for myopericarditis was initiated with high-dose ibuprofen and the patient improved clinically, with resolution of chest pain and cardiac enzyme elevation, and normalization of his EKG. A throat swab returned ß-hemolytic Group A Streptococcus on hospital day #4, and he was discharged in stable condition to complete a course of penicillin.
Group A Streptococcus is a common cause of bacterial pharyngitis. The Centor Score for predicting Streptococcal pharyngitis based on clinical symptoms can aid in decision making. When the clinical suspicion is high for streptococcal infection, a throat culture (sensitivity 90-95%) or PCR-based test should be performed as rapid antigen detection tests for streptococcal organisms have limited sensitivity (70-90%, depending on technique). Throat culture is the gold standard for diagnosing acute Streptococcal pharyngitis.
Acute non-rheumatic streptococcal myocarditis has been reported to mimic ACS in young patients presenting with chest pain that have troponinemia and ST elevation. Descriptive studies have demonstrated that over 95% of cases of myopericarditis in the setting of streptococcal pharyngitis or tonsillitis occur in young males (average age 28.6), and almost all present with chest pain, diffuse ST segment elevation, and elevated CK, CKMB, and troponin. Many of these patients (up to 67% in one study) underwent cardiac catheterization despite their young age and very few risk factors. In the setting of an acute infection in a young patient, it is important to recognize myopericarditis in order to avoid unnecessary invasive testing. While ACS should always be on the differential diagnosis in a patient presenting with chest pain, it is important to recognize myopericarditis as a potential cause of chest pain in a young person with acute streptococcal infection.
Society of General Internal Medicine (SGIM) 37th Annual Meeting, San Diego, CA; 04/2014
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