HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
53-year-old male admitted to the Cardiac Intensive Care Unit (CICU) after recovering from cardiorespiratory arrest in the street.

Personal history
Arterial hypertension under treatment with enalapril 20 mg.
Type 2 diabetes mellitus being treated with metformin.
Hyperuricaemia with several episodes of gouty arthritis. On treatment with allopurinol.

Present illness
Witnesses report that, while working (cook) and without reporting any previous symptoms, he fainted with loss of consciousness. After the initial approach by the witnesses, 112 was contacted, the absence of breathing or signs of life was detected and basic cardiopulmonary resuscitation manoeuvres were started. After 7 minutes, following the arrival of Basic Life Support (112), a defibrillable rhythm is detected by AED. Up to 4 shocks with the corresponding 30:2 cycles were applied together with 2 boluses of adrenaline and 300 mg of amiodarone.
After the fourth shock, the patient recovered sinus rhythm at 92 bpm and was transferred to the CICU sedated, intubated and connected to mechanical ventilation.

Physical examination
Sedoanalgesia. RASS -4. Pupils isochoric, miotic and reactive. BP 95/45; HR 125 bpm; peripheral O2 saturation 100% with FiO2 of 100%.
Rhythmic, tachycardic heart sounds without murmurs. Bladder murmur preserved bilaterally.
Abdomen slightly distended and tympanic. Bowel sounds present.
Lower limbs without oedema and bilateral pulses present and symmetrical.

COMPLEMENTARY TESTS
CBC: haemoglobin 14.5 g/dl; leucocytes 12,900 (36 % N); platelets 191.000; prothrombin activity 100 %; creatinine 1.2 mg/dl; GFR (MDRD-4) 67 ml/min; glucose 293 mg/dl; BUN 17 U/L; sodium 142 mee/l; potassium 3.9 meq/l; GOT 197 U/l; GPT 159 U/L; troponin I 0.045 ng/ml; NT-proBNP 636 pg/ml; CRP < 5 mg/l. Peak troponin I: 3 ng/ml.
Urine toxicity: cocaine, amphetamines, cannabis negative.
Chest X-ray: slight increase in cardiothoracic index. No evidence of infiltrates. Endotracheal tube is centred and normally positioned.
A-B balance on arrival: pH 7.34; pO2 427; pCO2 48; HCO3 25.9; lactic 7.6 mmol/l.
Transthoracic echocardiography: slightly hypertrophic left ventricle with segmental alterations of contractility. Moderately reduced left ventricular systolic function. Prolonged left ventricular relaxation (E/é 9). Absence of valvular heart disease. Right ventricle of normal size with normal systolic function.
Cranial CT: no significant alterations in the density of the brain parenchyma.
Ventricular system of normal size and morphology, without displacements with respect to the midline. No signs of intracranial bleeding were observed.
Cardiac magnetic resonance: non-dilated left ventricle with moderate left ventricular dysfunction. Intramyocardial patchy intramyocardial enhancement in anterior and posterior mid-apical face. Findings compatible with acute myocarditis.

EVOLUTION
The patient was admitted to the CICU and femoral venous access was channelled for induced hypothermia for the first 24 hours at 33°C. He was kept sedated and anaesthetised. He remained sedated and relaxed, with a tendency to bradycardia and arterial hypotension. The internal environment was corrected and lactacidemia and pH were normalised.
After 24 hours of hypothermia, progressive rewarming began, relaxation was withdrawn and sedation was gradually discontinued. Seventy-two hours after admission, the patient presented with abnormal movements, such as shivering, coinciding with an increase in temperature (38°C), for which reason an EEG was requested, which ruled out the presence of status convulsus. Antibiotic therapy was intensified (ceftriaxone + clindamycin) after finding a right basal infiltrate on X-ray, probably related to aspiration during intubation. Weaning progressed to extubation on the 5th day. The cranial CT scan after extubation showed no alterations of interest.
Monitoring in the CICU detected the presence of ventricular extrasystoles without sustained arrhythmias. Coronary angiography showed coronary arteries free of significant obstructive lesions. Once on the hospital ward, he remained in asymptomatic rehabilitation. Cardiac magnetic resonance imaging showed patchy intramyocardial uptake compatible with myocarditis and left ventricular function was moderately depressed (38%). Two weeks after admission, a single-chamber ICD was implanted, without incident, for secondary prevention of sudden death secondary to cardiomyopathy due to myocarditis.

DIAGNOSIS
Cardiorespiratory arrest recovered.
Aspirative pneumonia.
Cardiomyopathy secondary to myocarditis.
