A Rare Case of Acute Myocarditis

Background: Syntomatic Esptein-Barr virus (EBV) acute infection is more common in adolescents and young adults, classically manifesting as infectious mononucleosis. Although this is a common disease, complications are rare.

Objective: to report rare complications of EBV infection in one child.

Methods: We present the case of a 10 years old child admitted for persisting fever (medicated with amoxicillin PO for a tonsillitis a week earlier), associated with vomiting and abdominal pain in the right hypochondrium. The blood count revealed: WBC 13700 (N 68%), CRP 5,3mg/dL, ALT 31U/L and AST 240U/L and the abdominal ultrassound showed an acute acalculous cholecystitis. She was medicated with cefuroxime and metronidazol ev. After 2 days, she suddenly began chest pain, hemoptysis, respiratory distress, hypoxemia, paleness, tachycardia, hypotension, pulmonary crackles and hepatomegaly. Biochemistry revealed WBC 16900 (N 78,4%), ESR 45mm/h, AST 224U/L, ALT 79U/L, CK 1361U/L, CK-MB 211U/L, LDH 1377U/L, CRP 18.38mg/dL, D-dimers 6536ng/ml, Troponin 8184ng/L, NT-proBNP 33530pg/mL. EBV serology was positive. Cardiac monitorization showed ST segment elevation. Thoracic-CT revealed ARDS and right pleural effusion and the showed biventricular dysfunction and pericardiac effusion, compatible with cardiogenic shock. Inotropic therapy was started and she was transferred to a Pediatric Intensive Care Unit, under mechanical ventilation. On admission, the patient was hemodynamically unstable with an episode of ventricular tachycardia and was treated with amiodarone, adrenaline and dobutamine. She was discharged under treatment by carvedilol, linisopril, ivabradine, espironolactone and furosemide, but kept a moderate left ventricular dysfunction.

Conclusion: The initial clinical presentation suggesting mononucleosis and the positive serology for EBV were essential to establish the diagnosis of acute myocarditis, a rare complication of EBV infection.