Fig. 2. Initial chest X-ray revealed interstitial pulmonary edema. received ventilator care. Intravenous hydration and inotropic support with dopamine, noradrenaline, and dobutamine were performed. On the next day, her clinical condition gradually improved and the intubation tube could be removed. Cardiac troponin I were decreased to 0.857 ng/mL. To identify the cause of myo- carditis, viral antibody titers, such as coxsackie virus, adenovi- rus, rubella virus, mumps virus, cytomegalovirus, and human herpes virus, were checked. Among them, coxsackie virus A4, A16, B1, and B3, and adenovirus antibody titers were low posi- tive (<1:16 dilution), and coxsackie virus B4 antibody titer was high positive (1:256 dilution). In the follow-up echocardiogram 1 week later, LV systolic function was markedly improved and the estimated ejection fraction was 62%. She was getting bet- ter and was discharged on the 10th hospital day. She has taken angiotensin-converting enzyme inhibitors to prevent cardiac decompensation. Four weeks later, a colonoscopy was performed. Colonos- copy showed ulceration with stenosis in the terminal ileum and Oh IS, et al: Acute Myocarditis in Crohn’s Disease 513 Fig. 1. Sinus tachycardia was noted in 12-lead electrocardiogram. multiple aphthous ulcers in the rectum (Fig. 5A and B). Rectal biopsy revealed a non-caseating granulomatous inflammation consistent with Crohn’s disease (Fig. 5C). The Crohn’s disease activity index was 177. We started treatment with oral steroids and mesalazine and her symptoms of abdominal pain and diar- rhea improved. The disease has been well controlled with main- tenance therapy using mesalazine and azathioprine. Six months later, the antibody titer for coxsackie virus B4 was not changed (1:256 dilution), indicating that myocarditis was not caused by coxsackie virus infection. DISCUSSION Crohn’s disease can affect the GI tract as well as cause ex- traintestinal complications.1 Extraintestinal manifestations of IBD occur in 42% of patients with colonic disease and 23% of patients with small bowel involvement.4 The main sites of extraintestinal manifestation are the joints (14% to 39% of pa- tients), the skin (15%), the eye (4%), and the oral cavity (aphthous stomatitis, 4%).1,5 Rarely, cardiac problems such as pericarditis, pericardial effusion, myocarditis, endocarditis, and arrythmias can occur, but these can be fatal.6 These cardiac manifestations may also develop due to treatment side effects.7,8 Myocarditis may be more common at the beginning of IBD exacerbation and there is usually more than one extraintestinal manifestation present, but there is no direct relationship of the cardiac symptoms to disease activity.5 We found a case of acute myocarditis presenting as the initial complication of mildly ac- tive Crohn’s disease. Viral and post-viral myocarditis remain major causes of acute and chronic dilated cardiomyopathy.9 To date, diagnosis of viral myocarditis has generally been based on the isolation of virus from another site, and the demonstra- tion of a fourfold or greater rise in antibody titer from acute to convalescent sera.10 But the viral antibody titer of our case was not changed from acute to convalescent phase. Moreover, the sero-prevalence of coxsackie virus B4 in general population was not low (range, 9.3% to 19.1%).11 So, we assumed that her