Five pieces of myocardial tissue from right ventricular side of interventricular septum were obtained and sent for both pathological examination and tissue polymerase chain reaction (PCR) for all cardiotropic viruses including influenza type A and B, adenovirus, enterovirus, parvo virus B-19, cytomegalovirus, Human herpesvirus 6 (HHV-6) as well as the novel coronal virus.
Tissue PCR for all cardiotropic pathogens and the novel corona were negative. Autoimmune and connective tissue disease serology was unremarkable.
The microscopic exam of tissue demonstrated the myocardial fibers with multiple foci of mixed infiltration of inflammatory cells including lymphocytes, eosinophils, macrophages and multinucleated giant cells associated by focal myocyte damage and areas of fibrosis mainly in subendocardial areas compatible with active myocarditis highly suggestive for GCM. (Figure 3)
Immediately after reporting the pathology examination, a combined immunosuppressive therapy with IV pulse of methylprednisolone (500 mg for 3 days) and intravenous immune globin ([IVIG (500 mg/kg for 3 days)] was prescribed for the patient. The IV pulse therapy with methylprednisolone was followed by 1mg/Kg oral prednisolone which was tapered by 5 mg daily. The tablet of mycophenolate mofetil 1000 mg, 2 times daily got also started for her. The oral tacrolimus, 1mg two times daily got also started for her and adjusted to achieve the goal for a 12 hours trough whole blood level of 10-15 ng/ml for her first 6 months.
On the third day of treatment, the patient’s clinical condition and symptoms were remarkably improved and we could decrease and stop the IV inotrope and change the diuretic to oral doses. At the end of the week her echocardiographic findings were significantly improved, LVEF increased to about 30%, TAPSE to 14 mm and RV sm to 8 cm/sec.
The hospital course was uneventful and she had no arrhythmias and/or hemodynamic deterioration. Reviewing the 48-hour ECG Holter monitoring showed no abnormalities in terms of arrhythmias and/or atrioventricular block and the patient was discharged after a week with a good clinical condition a normal kidney and liver function test, an NT-Pro BNP of 1580 pg/ml and a normal CTnI . A week later, the patient continued to be free of symptoms and her new echocardiography showed further improvement; mild LV enlargement with an EF to 40 %, the apical segment of LV was still severe hypokinetic. mild to moderate MR, near normal RV size and function with a TAPSE of:18 mm and RVsm of 11 cm/sec and mild TR and IVC diameter of 17 mm with good respiratory collapse.
The prednisolone daily dose was tapered to 30 mg, 2 grams daily dose of mycophenolate mofetil and tacrolimus was continued for her. At the end of 6th month of treatment, she had no clinical symptoms, the echocardiography demonstrated the same findings, so the dose of oral prednisolone was reduced to 10 mg/day. On the 3rd and 6th month of follow-up her NT pro BNP level was 19.5 pg/ml and 30 pg/ml respectively.