Lymphocytic Myocarditis in the Late Preterm Patient

Childbearing Poster Presentation Background A woman was transferred to us at 35 weeks gestation with gastroenteritis symptoms and suspected preeclampsia. Further evaluation revealed more than a simple case of preeclampsia. Multiple differential diagnoses were considered. Case Physical examination was unremarkable on admission. The woman's blood pressure was normal and viral gastroenteritis was suspected. She reported headache and nausea, but symptoms improved after administration of antiemetics and antacids. Subsequently, she became febrile and oliguric and developed epigastric pain. Abdominal magnetic resonance imaging was unremarkable, pancreatitis was ruled out by abdominal ultrasonography, and the hepatitis panel result was negative. She then developed a diffusely tender abdomen, at which point chorioamnionitis was suspected, antibiotics were started, and an induction of labor was initiated. After the initiation of the induction of labor, dyspnea was noted and a chest X-ray was obtained to rule out pneumonia. She remained febrile, hypotensive, tachycardic, and tachypneic throughout labor but had a spontaneous vaginal delivery. The infant was transferred to the neonatal intensive care unit. No improvement in symptoms occurred after the woman gave birth. Concerns for worsening pneumonia and the potential for developing pulmonary edema led to an electrocardiogram (EKG); repeat chest X-ray, blood, urine, and placental cultures; pregnancy-induced hypertension labs; cardiac enzymes; arterial blood gases; and an echocardiogram. An arterial line was placed and a diuretic was administered. Cardiology was consulted and the woman was transferred to cardiac catheterization lab so that a cardiac catheterization could be completed and endomyocardial biopsies could be obtained. Coronary arteries were patent and the ejection fraction was less than 10%. She developed ventricular fibrillation, was defibrillated twice, stabilized, placed on extracorporeal membrane oxygenation, and had an aortic balloon pump inserted in the operating room. She was transported to the cardiac intensive care unit for further management. Because the results of her myocardial recovery reveal lymphocytic myocarditis, cardiology determined that a biventricular assist device (BIVAD) will be required for a prolonged period to allow time for myocardial recovery. Her aortic balloon pump was removed and she was transferred out for BIVAD placement and further evaluation. Conclusion Acute lymphocytic myocarditis is rare and difficult to diagnose except by biopsy and is usually an immune response to a viral infection. Case reports in pregnancy are almost nonexistent. Our labor and delivery unit routinely cares for women with preeclampsia, and this woman's preliminary laboratory results determined routine care. Persistence of her symptoms indicated the need for further testing, which revealed significant abnormalities, prompting additional testing for less common alternate diagnoses. Ultimately, her rare diagnosis of acute lymphocytic myocarditis was determined after delivery. We learned that pregnancy could complicate and conceal a variety of ailments. Symptoms as common as unresolved persistent nausea and vomiting, tachycardia, and tachypnea require further testing, which in turn may lead the healthcare team to eliminate additional differential diagnoses. A well-coordinated interdisciplinary team makes a great impact on the outcome of patients in the mother–infant unit.