Cardiac MRI in Identifying Myopericarditis Mimicking STEMI in a Patient with HIV: A Case Report

BACKGROUND Acute myopericarditis can clinically and electrocardiographically mimic ST-elevation myocardial infarction (STEMI), leading to misdiagnosis and delayed treatment. In people living with HIV (PLWH), particularly those untreated, impaired immunity and viral-driven inflammation amplify cardiac involvement. Autopsy data suggest a myocarditis prevalence rate of up to 50% in AIDS patients, yet clinically overt cases remain rare. Diagnostic ambiguity can precipitate unnecessary invasive procedures and contribute to HIV-associated cardiomyopathy, an AIDS-defining illness. CASE REPORT A 62-year-old white man with untreated HIV, noncompliance with antiretroviral therapy, heart failure with reduced ejection fraction (HFrEF), and active substance use presented with 3 days of chest pressure and progressive dyspnea. Pre-hospital ECG demonstrated inferolateral ST-segment elevations, triggering STEMI activation. Coronary angiography revealed multivessel obstructive stenoses with preserved TIMI-3 flow and no thrombotic occlusion. Transthoracic echocardiography showed global left ventricular hypokinesis (EF 24%) and moderate pericardial effusion. Cardiac magnetic resonance imaging demonstrated elevated native T1 times, diffuse pericardial enhancement, and absent late gadolinium uptake, confirming acute myopericarditis. Serologic evaluation included coccidioidomycosis titers, viral panel, and tuberculosis workup. Treatment comprised colchicine, ibuprofen, aspirin, high-intensity statin, goal-directed medical therapy for heart failure, reinitiation of antiretroviral therapy, and prophylaxis for opportunistic infections. CONCLUSIONS This case illustrates the diagnostic challenge of distinguishing myopericarditis from STEMI in people living with HIV. Accurate recognition using advanced imaging techniques such as cardiac MRI can prevent unnecessary invasive procedures and facilitate targeted therapy. Multidisciplinary care is vital to optimizing outcomes, particularly in patients with complex comorbidities and barriers to care.