Cardiovascular magnetic resonance imaging and endomyocardial biopsy in giant cell myocarditis: a case report on diagnostic challenges and future perspectives

Figure 1. Initial cardiac magnetic resonance imaging. Cardiac magnetic resonance imaging showed ubiquitously increased T1 (A: T1 native: 1489 ms; ECV: 41.2%) and T2 values (B: 50 ms). Furthermore, multifocal late gadolinium enhancement (C, D: arrows) including the septal and lateral region as well as the anterior insertion point, extending into the right ventricular wall (D: ‘hook sign’), was seen in phase-sensitive inversion recovery imaging. HS, hook sign; LA, left atrium; LV, left ventricle; PE, pericardial effusion; PLE, pleural effusion; RA, right atrium; RV, right ventricle.

Figure 2. Pulmonary lymph nodes and biopsy results. Cardiovascular magnetic resonance imaging revealed bilateral hilar lymphadenopathy (A, asterisk). A lymph node biopsy revealed non-necrotizing granulomas (B) containing multinucleate giant cells (C), as typically seen in sarcoidosis. Histological images were kindly provided by the Institute of Pathology, University Medical Center of Goettingen, Germany.

Figure 3. Right ventricular endomyocardial biopsy. Endomyocardial biopsy showed diffuse fibrosis and severe inflammation (A: blue areas; Masson trichrome). The presence of giant cells (B: asterisk) and increased amounts of eosinophilic granulocytes (B: arrows; Giemsa) was indicative of a diagnosis of giant cell myocarditis. Histological images were kindly provided by the Institute for Pathology and Neuropathology, University Hospital Tuebingen, Germany.

Figure 4. Cardiac magnetic resonance imaging eight months after symptom onset. The eight-month follow-up cardiac magnetic resonance imaging showed persistent but overall reduced late gadolinium enhancement (arrows) in phase-sensitive inversion recovery imaging. HS, hook sign; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.