Myocarditis Associated With Herpes Zoster in a 91-Year-Old Woman: A Rare Cardiac Complication With Favorable Outcomes

Figures

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  Figure 1. Herpes zoster rash on the patient’s back. Maculopapular and vesicular lesions on an erythematous base distributed along the right T6 dermatome, consistent with herpes zoster reactivation.

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  Figure 2. Electrocardiogram on admission A 12-lead ECG demonstrating sinus rhythm without acute ischemic changes.

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  Figure 3. Chest radiograph on admission. The arrows highlight radiographic findings of pulmonary congestion and pleural effusion, which are significant because they demonstrate acute left-sided heart failure, in this case secondary to myocarditis. These findings support the clinical diagnosis and illustrate the degree of cardiac decompensation of the patient at presentation.

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  Figure 4. Strain analysis on transthoracic echocardiogram. (A) Admission: bull’s eye plot of global longitudinal strain showing markedly reduced values (-9.5%) and depressed left ventricular ejection fraction (LVEF 35%), consistent with impaired systolic function. (B) Two-week follow-up: improvement in global strain (-13.2%) with recovery of LVEF to 50%. TABIQUE: septal (refers to interventricular septum); INF: inferior LAT; LAT: lateral ANT; ANT: anterior SG; SG: strain global (GLS); GLS: global longitudinal strain; FE: fractional ejection (LVEF); LVEF: left ventricular ejection fraction

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  Figure 5. Mitral regurgitation on transthoracic echocardiogram. The arrows mark the mitral regurgitant jet on color Doppler imaging. This is significant as it illustrates functional mitral regurgitation associated with left-sided ventricular dysfunction, a common feature in acute myocarditis. However, since no prior echocardiographic study was available, it is uncertain whether the mitral regurgitation was present before and worsened or developed as part of the acute myocardial inflammation. The reduction in the regurgitant jet on follow-up emphasizes improvement in the cardiac function after treatment. (A) Admission: color Doppler imaging demonstrating severe mitral regurgitation with a prominent regurgitant jet. (B) Two-week follow-up: significant reduction in mitral regurgitation compared with baseline.

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  Figure 6. Tricuspid Doppler on transthoracic echocardiogram. The arrows identify the tricuspid regurgitant jet used to estimate pulmonary artery systolic pressure. The significance of demonstrating this is the presence and subsequent resolution of pulmonary hypertension, indicating the recovery of right ventricular function as myocarditis improves. (A) Admission: continuous-wave Doppler across the tricuspid valve showing elevated velocity (3.5 m/s) corresponding to a calculated right ventricular systolic pressure of ~49 mmHg, consistent with pulmonary hypertension. (B) Two-week follow-up: improvement with reduced velocity (2.1 m/s) and calculated gradient of 18.6 mmHg, indicating resolution of pulmonary hypertension. IT Vmax: tricuspid insufficiency maximum velocity; IT GPmax: tricuspid insufficiency maximum pressure gradient