A Diagnostic Dilemma: Urosepsis Mimicking ST-elevation Myocardial Infarction: A Case Report and Review of the Literature

Acute coronary syndrome (ACS) remains a leading global cause of morbidity and mortality. Healthcare systems worldwide have established national guidelines to facilitate the timely identification and transfer of patients with ST-elevation myocardial infarction (STEMI) to centers capable of performing primary percutaneous coronary intervention (PCI). Typically, ST-segment elevation (STE) on an electrocardiogram (ECG) is indicative of STEMI, prompting early intervention. However, rare cases of STE have been documented in the setting of sepsis or septic shock, with subsequent coronary angiography or imaging revealing normal coronary arteries. There is limited information regarding the exact mechanisms responsible for STE in the context of sepsis. We report the case of a 79-year-old Indian female who presented with epigastric pain and vomiting. Her initial ECG showed STE in leads I, aVL, and V2, accompanied by markedly elevated cardiac biomarkers. In accordance with the national STEMI network protocol, she received prehospital dual antiplatelet therapy and intravenous heparin before hospital arrival and was transferred directly for primary PCI. She was initially managed as a case of ACS; however, coronary angiography demonstrated normal coronary arteries. Further evaluation led to the diagnosis of septic shock secondary to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli urosepsis, requiring mechanical ventilation, four concurrent vasopressors, and continuous venovenous hemodiafiltration, with complete clinical recovery. Notably, her ECG abnormalities resolved within 72 h following prompt management of the septic shock. While STEMI remains the most common cause of STE on ECG, sepsis and septic shock are rare but important differential diagnoses. The underlying pathophysiology may involve inflammatory myocardial injury, transient coronary vasospasm, or global hypoperfusion. This case highlights the critical importance of recognizing septic shock as a potentially life-threatening STEMI mimic, to avoid unnecessary invasive interventions and to guide appropriate, targeted management.