[Fulminant myocarditis in a patient with a history of autoimmune hepatitis]

Myocarditis is an inflammatory disease of the cardiac tissue of variable etiology, both infectious and non-infectious. Its presentation can range from asymptomatic to fulminant forms. We present the case of a 24-year-old male patient with a history of autoimmune hepatitis in compensated cirrhotic phase. He consulted for dyspnea of 15 days evolution. He had presented gastrointestinal symptoms one month prior to the consultation. Physical examination revealed signs of heart failure. Laboratory examination showed elevated cardiac biomarkers and acute on chronic hepatic insufficiency. A transthoracic echocardiogram showed severe global biventricular dysfunction. The diagnostic hypotheses were cardiac involvement due to reactivation of autoimmune disease versus viral myocarditis. An MRI was performed which confirmed very severe ventricular dysfunction and late gadolinium enhancement suggestive of myocarditis. It was indicated treatment with methylprednisolone pulses. On the first day of hospitalization he evolved with clear signs of cardiogenic shock and ventricular arrhythmia refractory to medical treatment. After an exhaustive multidisciplinary evaluation, which was difficult due to his clinical condition, the possibility of a heart transplant was considered. Extracorporeal membrane oxygenation (ECMO) support was established as a bridge to transplantation. On the seventh day after ECMO, and after great improvement of the hepatogram parameters, the patient received a heart transplant. He had good postoperative evolution. However, he died two months after the transplant due to an opportunistic infection. The results of the biopsy of the explanted organ confirmed the diagnosis of lymphocytic myocarditis.