Extensive Loss of Myocardium due to Lymphocytic Fulminant Myocarditis: An Autopsy Case Report of a Patient with Persistent Cardiac Arrest for 25 Days

Figures

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  Figure 1.. Serial electrocardiogram findings for a 52-year-old man. A: A 12-lead electrocardiogram at the previous hospital. B: A 12-lead electrocardiogram upon admission to our hospital (Day 1). C: Post Impella® insertion: Complete atrioventricular block (Day 1). D: Asystole (Day 4).

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  Figure 2.. A comparison of the biopsy and autopsy tissues using tissue staining and immunohistochemistry (IHC). Biopsy tissue sections were obtained and stained with A) Hematoxylin and Eosin (H&E) staining, B) Azan, C) anti-CD8 antibody, and D) anti-CD163 antibody. Autopsy tissue sections were stained with E) H&E staining, F) Azan, G) anti-CD8 antibody, and H) anti-CD163 antibody. The representative H&E staining section (A), and immunohistochemistry (IHC) with anti-CD8 and anti-CD163 antibodies showed increased numbers of infiltrating lymphocytes (C) (lymphocytes: 10-20 cells/high-power field) and macrophages (D). Although fibrosis was rarely observed in biopsy samples (B), severe fibrosis was observed in the autopsy sample (F). No viable cardiomyocytes were observed in the autopsy sample (E). Increased infiltration of inflammatory cells was observed in the autopsy sample (G, H). Bar scales were 50 μm for H&E staining (A), 100 μm for Azan, and 20 μm for H&E staining (E) and IHC staining.

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  Figure 3.. Findings of echocardiography from a parasternal long-axis view. A: Day 1: Diastolic phase. Increase in thickness and edematous changes of the myocardium and an impaired left ventricular systolic function were observed. B: Day 3: Left panel: diastolic phase, Right panel: systolic phase. Additional increases in thickness and edematous changes in the myocardium were observed with a severely reduced left ventricular systolic function. C: Day 8: Increases in thickness and edematous changes in the myocardium were still observed with pericardial effusion. D: Day 16: The increased thickness and edematous changes in the myocardium as well as the pericardial effusion had disappeared.

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  Figure 4.. Clinical course.

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  Figure 5.. Macroscopic findings. A: Atrophy of both ventricles and whitish fibrosis of the posterior wall of the left ventricle were observed. B: Residual viable cardiomyocytes were observed only in the free wall of the left and right ventricle (yellow areas). C: The inserted Hematoxylin and Eosin staining Figure shows the border area of viable cardiomyocytes (*) and fibrosis without viable cardiomyocytes (**). Many lymphocytic infiltrates were found at the border area (arrow heads). Bar scale: 100 μm. D: There was no viable cardiomyocytes in most of the myocardium. Bar scale: 200 μm.