An unusual case of myocarditis as the initial presentation of Epstein Barr virus (EBV) infection

Male 19 years old, in the absence of risk factors presents in the emergency room for retrosternal pain, headache and photophobia. In the two days prior to admission fever and diarrhea. Negative for Sars-Cov-2 infection. On auscultation no pericardial rubbing.ECG showed RS, HR 95 bpm, negative T wave in DIII. The echocardiogram was normal. Serial determinations of high sensitivity troponin (TnHS) were positive and increasing (1st TnHS: 2780, 2nd 3435 ng/L;cut off: 2.3-19.8 ng/L). In the first days of hospitalization, the apyretic patient presented frequent episodes of chest pain that were accentuated with inspiration and with the supine position, in the absence of other diagnostic criteria of pericarditis. Therefore therapy with paracetamol was initially set, subsequently associated with anti-inflammatory therapy with ibuprofen and beta-blocker. The episodes of chest pain progressively disappeared, associated with negativization of TnHS in 4th day of hospitalization. The same day fever appeared, reaching up to 39 °C, worsening asthenia, abdominal pain localized to the upper quadrants and pharyngodynia associated with pharyngeal plaques. COVID-19 swab was repeated and throat swab, coprocultures and urinary antigens were collected for the detection of Legionella and Pnemococcus. All of these tests were negative. Finally, viral serology was collected which showed a possible acute viral infection by EBV with positive IgM anti-VCA (96.7 U/ml) and Ig anti-EA (83 U/ ml), then confirmed by the molecular identification of EBV-DNA (copies of DNEPA 7559). Abdomen ultrasound instead showed splenomegaly (14x 6.5 cm) with homogeneous echostructure.On the 5th day, new alterations in repolarization appeared on the ECG trace with negativization of the T wave also in aVF and hypokinesia of the SIV posterior to the basal segment appeared on the echocardiogram, not previously known, even in the presence of normal biventricular systolic function. On day 6 the patient underwent cardiac MRI which confirmed the diagnosis of acute myocarditis showing inflammatory edema in T2-weighted sequences of the posterior mid-basal segments and late enhancement in T1-weighted sequences with subepicardial distribution of the posterior middle segments. Finally, low dose angiotensin-converting enzyme inhibitors was introduced in therapy and in the 10th day, apiretic and in the absence of abdominal and thoracic symptoms, the patient was discharged.