Fatal methyldopa-associated granulomatous hepatitis and myocarditis

A 78-year-old woman developed spiking fever of obscure etiology while receiving long term therapy with methyldopa and died suddenly seven days after admission to the hospital. Autopsy showed widespread granulomas in the liver, spleen, lymph nodes and bone marrow, interstitial myocarditis with granulomatous features and renovascular vasculitis. Eosinophils were prominent in the granulomas and in the myocardium consistent with a drug-induced cell mediated hypersensitivity reaction presumably triggered by methyldopa. The need for a careful drug history in fever of obscure etiology is emphasized.