case_images: PMC11718392_01
case_images: Electrocardiograms and telemetry. (A) Initial electrocardiogram 2 months prior to presentation. Sinus rhythm, with normal axis. Non-specific T wave changes. QTc 419 ms. (B) Electrocardiogram on presentation Day 1:slow ventricular tachycardia/accelerated idioventricular rhythm noted by atrioventricular dissociation, indeterminate axis, ST segment elevation secondary phenomenon to ventricular tachycardia. QTc 455 ms. (C) Subsequent electrocardiogram Day 1:non-specific intraventricular block, noted ST elevation as a secondary phenomenon, change in axis (extreme axis). QTc 488 ms. (D) Electrocardiogram Day 3:sinus rhythm with improvement in ST-T wave changes as well as QRS interval widening. Right axis deviation. QTc 414 ms. (E) Electrocardiogram Day 7:continued improvement in ST-T wave changes. Near normalization of axis. QTc 469 ms. (F) Telemetry with ventricular fibrillation.
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case_images: His 12-lead electrocardiogram (ECG) showed slow ventricular tachycardia (VT) with secondary ST segment changes (Figure 1A-E). After completion of the catheterization, he had ventricular fibrillation but had return of spontaneous circulation with advanced cardiovascular life support (Figure 1F).
case_images: Endomyocardial biopsy. (A) Endomyocardial biopsy specimen shows myocardium with diffuse involvement by active lymphohistiocytic myocarditis (Haematoxylin and eosin, x80 original magnification). (B) Lymphohistiocytic inflammation with associated myocyte injury (arrow), with features including hypereosinophilic damaged cells (i.e. increased staining with eosin), loss of cross-striations, and shrunken myocytes with degenerative changes (Haematoxylin and eosin, x400 original magnification).
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case_images: No giant cells, eosinophils, or evidence of sarcoidosis were seen (Figure 2).
case_images: Cardiovascular magnetic resonance imaging basal short axis. (A) Steady-state free precession image, normal wall thickness and a small pericardial effusion. (B) Late Gadolinium Enhancement images with sub-epicardial enhancement in the basal inferolateral segment (arrows). (C) Native T1 map demonstrating severely increased T1 values in the basal inferolateral segment 1151 ms (normal 1013 +- 35 ms) (arrows). (D) T2 weighted black blood images demonstrating increased signal in the basal inferolateral segment suggestive of myocardial oedema (arrows).
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case_images: There were no findings of prior ischaemic damage. There was a small circumferential pericardial effusion without the evidence of pericardial inflammation (Figure 3).