Images in Cardiovascular Medicine Parvovirus B19-Induced Myocarditis Mimicking Acute Myocardial Infarction Clarification of Diagnosis by Cardiac Magnetic Resonance Imaging

n 18-year-old man with no previous cardiac historypresented to his local hospital complaining of severechest pain. One day before admission, he was hit in the chestby a ball during a basketball game. He did not notice anysymptoms and was able to finish the game; however, the nextday, he developed severe central chest pain. Cardiac tro-ponins were elevated at 79 g/L (normal range, 0 to 1.2 g/L). He subsequently underwent cardiac catheterization,which showed normal coronary anatomy with no significantstenoses. Subsequently, he had another episode of chest painthat was associated with diffuse ST elevation involving theanterior and lateral leads. The ST elevation persisted for 90minutes before subsiding spontaneously. On transfer, thepatient was specifically questioned about recreational druguse. He denied any use of cocaine, although he did admit tousing marijuana 1 week before admission. On examination,he was pain free and hemodynamically stable. An echocar-diogram showed minimal persistent ST segment elevation inthe anterior leads (Figure 1). A cardiac magnetic resonanceimaging (MRI) scan (Magnetom TRIO, Siemens, Germany;field strength 3 T) was performed to assess morphology ofmyocardial injury. This scan demonstrated normal left ven-tricular size with mild left ventricular systolic dysfunction(Movie I in the online-only Data Supplement). Left ventric-ular ejection fraction was calculated at 42% using QMassMR version 7.0.28 (Leiden, The Netherlands). There wassevere hypokinesis of the basal to midanterolateral, inferolat-eral, and inferior walls and hypokinesis of the midanteriorand apical segments. On delayed enhancement imaging, therewas diffuse patchy midmyocardial and epicardial late gado-linium enhancement involving these segments (Figure 2Aand B). The subendocardium was spared. T2-weighted imag-ing revealed high-intensity signal in these areas, suggestingthe presence of myocardial edema (Figure 3). On rest perfu-sion, a perfusion defect was seen, which involved the basal tomidlateral walls. Overall, the findings were strongly sugges-tive of myocarditis. Subsequently, his parvovirus B19 anti-body levels were noted to be elevated at 5.5 index value(normal range, 0 to 0.89 index value), confirming the diag-nosis of parvovirus B19-induced myocarditis. The patientwas commenced on angiotensin-converting enzyme inhibi-tors and discharged. He was reviewed in our clinic after 10weeks and reported feeling significantly better with nospecific ongoing symptoms. An echocardiogram showedimprovement in left ventricular function with improvement incontractility of the lateral wall (Movie II in the online-onlyData Supplement).