A Rare Case of Fulminant Myocarditis Leading to the Diagnosis of Systemic Lupus Erythematosus

Figure 1. Admission Electrocardiogram There is atrioventricular dissociation; the underlying rhythm is sinus with an accelerated junctional rhythm with aberrancy. ST-segment elevations are seen in the anteroseptal and lateral leads.

Figure 2. Cardiac Magnetic Resonance (A–C) Phase-sensitive inversion recovery showing delayed gadolinium enhancement in the subepicardial and midmyocardial region (noted by black arrows), suggestive of nonischemic myocardial injury. There is a small pericardial effusion, noted by white arrows. (D) Myocardial edema identified by T2 mapping (black arrow) with increased native myocardial T2 relaxation time (72 ms). (E) T1 mapping with regionally increased native T1 relaxation time (up to 1,275 ms in the anterior wall of the left ventricle), consistent with myocardial injury and possible early fibrosis (black arrow). (F) Extracellular volume fraction (ECV) map showing regionally increased ECV, again consistent with myocardial injury (black arrow).

Figure 3. Endomyocardial Biopsy (A) A high-power pathology slide showing inflammatory infiltrates composed of primarily lymphocytes. There are cardiomyocytes with indistinct borders, loss of nuclei, and lymphocytic encroachment (blue triangles) consistent with myocyte injury and necrosis. (B) More evidence of myocyte injury and necrosis (blue triangles). There are scattered inflammatory cells (neutrophils; red triangle) secondary to the tissue damage. The overall findings are consistent with lymphocytic myocarditis.

Figure 4. SLE Diagnostic Criteria The 2019 European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) criteria, adapted into a table from Ameer et al.1 The diagnostic criterion that was met by our patient is bolded. SLE, systemic lupus erythematosus.

Figure 5. Follow-Up Electrocardiogram Obtained 4 months after initial presentation. He is now in normal sinus rhythm with benign early repolarization. There is resolution of the ST-segment changes in the anteroseptal and lateral leads.