Correspondence Between Delayed Enhancement Patterns in Multislice Computed Tomography and Magnetic Resonance Imaging in a Case of Acute Myocarditis
A 42-year-old man who was an active smoker with no significant medical history presented with severe substernal pain 5 days after acute enteritis. The examination showed mild fever, blood pressure of 113/75 mm Hg, and heart rate of 85 beats per minute.
The ECG showed sinus rhythm with incomplete left bundle-branch block. Laboratory tests showed elevated levels of troponin I (23 μg/L) and C-reactive protein (104 mg/L). Chest radiography was normal. Echocardiography showed subnormal left ventricular ejection fraction, mild global hypokinesia, and no pericardial effusion. ECG-gated, contrast-enhanced, 64-row multislice computed tomography (MSCT) showed normal coronary arteries and cine studies showed apical and lateral hypokinesia. A delayed acquisition performed 5 minutes after injection showed on 2.5-mm reformat images epicardial delayed enhancement (DE) of the lateral wall at the mid-left ventricle and basal levels and intramural and epicardial hyperenhancement of the apex (Figure, A and C).
Magnetic resonance imaging (MRI) was performed to confirm myocardial DE. Cine-MRI confirmed the loco-regional contraction anomalies; left ventricular ejection fraction was 40%. DE-MRI studies (10 minutes after gadolinium diethylenetriamine pentaacetic acid injection) confirmed the delayed-enhancement findings seen on MSCT with better contrast but with an excellent topographic match (Figure, B and D). No subendocardial DE was seen. Absence of involvement of the subendocardium, patchy distribution of DE in MRI, and normal coronary arteries on computed tomography (CT) led to the diagnosis of acute left ventricular myocarditis.
Although the usefulness of DE-MRI in the diagnosis of myocarditis has been well documented in the literature, similar DE areas seen on a delayed CT acquisition and compared with MRI had yet to be reported. The combination of coronary angiography and delayed myocardial imaging with CT in an emergency setting could be an alternative for the diagnosis of acute myocarditis that remains to be evaluated.