Tsutsugamushi myocarditis with congestive heart failure and persistent atrial standstill

Acute infectious myocarditis is primarily by viruses and bacteria, but sometimes by rickettsia. Tsutsugamushi disease is a febrile illness caused by Rickettsia tsutsugamushi, and has been prevalent in Korea since 1985. Characteristics of tsutsugamushi disease are fever, rash and eschar. Tsutsugamushi myocarditis is rare. Cardiac involvement may include ST-T changes, PR prolongation, mild mitral regurgitation, and perivascular inflammation with myocardial necrosis. We describe here a 50-year-old woman who complained of fever, orthopnea and chest pain. Work-up of the patient revealed abdominal scar, positive tsutsugamushi antibody, congestive heart failure with severe mitral and tricuspid regurgitation, persistent atrial standstill on electrophysiologic study, junctional rhythm and ST-T changes mimicking anterior myocardial infarction and myocardial inflammation with perivasculitis on endomyocardial biopsy. The patient's condition improved with doxycycline and inotropics. Persistent atrial standstill during was found at the one-year follow-up.