case report Gut and Liver, Vol. 6, No. 4, October 2012, pp. 512-515 A Case of Acute Myocarditis as the Initial Presentation of Crohn’s Disease In Soo Oh*, Chang Hwan Choi*, Ji Hoon Park*, Ju Wan Kim*, Bong Ki Cha*, Jae Hyuk Do*, Sae Kyung Chang*, and Gui Young Kwon† Departments of *Internal Medicine and †Pathology, Chung-Ang University College of Medicine, Seoul, Korea We experienced a case of acute myocarditis as the initial pre- sentation of Crohn’s disease. A 19-year-old woman was ad- mitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdom- inal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed intersti- tial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotro- pic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non- caseating granulomatous inflammation. She was diagnosed with Crohn’s disease presenting with acute myocarditis. (Gut Liver 2012;6:512-515) Key Words: Crohn disease; Myocarditis INTRODUCTION Crohn’s disease, an idiopathic inflammatory bowel disease (IBD), can affect any part of the gastrointestinal (GI) tract from the mouth to the anus, and can show extraintestinal manifesta- tions.1 Myocarditis is a rare extraintestinal complication of IBD that can occur as an initial manifestation of Crohn’s disease and also independently of bowel disease activity.2,3 We report here on a case of acute myocarditis as the initial presentation of Crohn’s disease and review the literature. CASE REPORT A 19-year-old woman was admitted with impaired con- sciousness. She was a university student and social drinker of less than 50 g per week. She had no specific medication and travel history. Other past medical history was unremarkable. She suffered from frequent diarrhea and abdominal pain for several years. Her diarrheal symptom had progressively worsened for 2 months before admission. Three days prior to admission, she presented with high fever, headache, and myalgia. On admission, her vital signs were unstable: blood pressure of 70/40 mm Hg, pulse rate 130 beats/min, body temperature 41.0oC, and respiratory rate 35/min. Her mental status was stuporous. The abdomen was diffusely tender and distended without palpable mass. Laboratory findings showed a white blood cell count of 21,440/mm3 with 92% neutrophil, hemoglo- bin 13.4 g/dL, platelet 332,000/μL, urea 10 mg/dL, creatinine 1.1 mg/dL, and C-reactive protein 92.9 mg/L. Cardiac troponin I and creatine kinase-MB were elevated to 5.32 and 16.66 ng/ mL, respectively. Human immunodeficiency virus antibody, hepatitis B surface antigen antigen, hepatitis C virus antibody, and anti-nuclear antibody were negative. The blood and urine cultures and stool examinations were not remarkable. A 12- lead electrocardiogram showed sinus tachycardia (Fig. 1) and a chest radiograph revealed a normal-shaped heart but interstitial pulmonary edema (Fig. 2). A Doppler echocardiogram showed dilated ventricles with akinesia of the basal to apical inferosep- tal, anteroseptal, anterior, and inferior left ventricular (LV) wall and severely impaired systolic function: the estimated ejection fraction was 38% (Fig. 3A and B). Fulminant myocarditis with acute LV failure was diagnosed. An abdominal-pelvic computed tomography scan showed active inflammatory wall thickening in the distal ileum and sigmoid colon, associated mesenteric hy- peremia and intervening normal segments of the ileum (Fig. 4). She was admitted to the intensive care unit with intubation and Correspondence to: Chang Hwan Choi Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 156-755, Korea Tel: +82-2-6299-1418, Fax: +82-2-6299-2017, E-mail: gicch@cau.ac.kr Received on August 24, 2010. Revised on November 13, 2010. Accepted on December 31, 2010. pISSN 1976-2283 eISSN 2005-1212 http://dx.doi.org/10.5009/gnl.2012.6.4.512 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.