Acute Heart Failure Due to Myocarditis

with Thyroid Dysfunction Comorbid :

A Case Report
A.N. 1
Alvirosa , Irnizarifka2

1GeneralPractitioner
2Departement of Cardiology and Vascular Medicine of UNS Hospital, Faculty of Medicine Sebelas Maret University

Methimazol

Background
Thyroid hormone
Myocarditis is inflammation of heart muscle and may involve myocytes,
intersitium, vascular element, and pericardium. Myocarditis that ↑ systolic ↑ diastolic ↓ vascular
associated with acute heart failure (HF) could lead to sudden death. contraction contraction resistence

Meanwhile, thyroid dysfunction can be a comorbid in HF.

↑ CO

Case
o Heart Failure
A 19-year-old man had fever (38 C),
dry cough, and sniffles 10 days prior
to hospitalization. Dyspneu, orthopnea, elevated JVP, crackles at both
lungs, caudolaterally heart border, lower limb edema, and massive Myocarditis
ascites also evinced. ECG revealed sinus tachycardia with LVH
↓inflammation
configuration. Chest x-ray revealed cardiomegaly and pulmonary edema.
Echocardiography showed dilated all chambers, and 15,3% LVEF with
↑ IL-1 receptor ↑ TNF
severe mitral and pulmonary regurgitation. Coronary CT angiography ↑ IL10 antagonist receptor

confirmed normal coronary arteries, while thyroid function test came out
hypertyroxinemia (FT4 20.52 and TSH 2.48). Intravenous IVIG
: block
Immunoglobulin (IVIG) and 10 mg methimazole was added to standard : stimulate
therapy of HF include 40 mg furosemide, 10 mg ramipril, and 5 mg Figure 1. IVIG and methimazole mechanism in improving HF
bisoprolol. After 2 months, clinical features were improved (functional
class I), echocardiography evaluation showed increase in LVEF (28,8%),
and FT4 test was normal.

Discussion
Myocarditis should be diagnosed with endomyocardial biopsy (EMB).
When EMB is not available, we can suspect myocarditis with the 2013
ESC task force criteria. Myocarditis with HF should be treated with
current HF guidelines. It was reported that IVIG therapy could improve
LVEF, reduced LVEDD, decreases incidence of VT/VF and AV Block. On
the other hand, thyroid hormone affects anatomy and physiology of
cardiovascular system. In presence of heart disease, pericardial disease,
HF, or arrhythmias, thyroid dysfunction merits a high level of clinical
suspicion. Figure 2. Initial LV function

Conclusion
Addition of IVIG therapy and controlling thyroid function with
methimazol on top of standard HF therapy did improve the clinical
features of acute HF due to myocarditis with thyroid dysfunction.

Reference
1.Grais IM, Sower JR. Thyroid and the heart. The American Journal of Medicine (2014). Vol 127 (8)
2.Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and
therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and
Pericardial Diseases. European Heart Journal (2013) 34, 2636–2648
3.Mavrogeni S, Markussis V, Bratis K, et al. Hyperthyroidism induced autoimmune myocarditis. Evaluation by
Cardiovascular Magnetic Resonance and endomyocardial biopsy. International Journal of Cardiology. (2012) 158 (1): 166-168
4.Yu DQ, Wang Y, Ma GZ, et al. Intravenous immunoglobulin in the therapy of adult acute fulminant myocarditis: A
retrospective study. Experimental andTherapeutic Medicine (2014) 7: 97-102 Figure 3. Evaluation LV function

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