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Follow-up assessment of myocardial calcification secondary to fulminant myocarditis with computed tomography

  • Congjun Zeng
    Affiliations
    Department of Radiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu, PR China
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  • Ying Song
    Affiliations
    Department of Ultrasound, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
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  • Weibing Tang
    Affiliations
    Department of Critical Care Medicine, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu, PR China
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  • Ze Chen
    Affiliations
    Department of Cardiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu, PR China
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  • Hailin Shen
    Correspondence
    Corresponding author. Department of Radiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Wansheng Street 118, Suzhou, Jiangsu 215028, People's Republic of China.
    Affiliations
    Department of Radiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu, PR China
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Open AccessPublished:July 03, 2022DOI:https://doi.org/10.1016/j.jcct.2022.06.138

      Keywords

      Abbreviations:

      VA-ECMO (venoarterial extracorporeal membrane oxygenation), CT (computed tomography), HU (Hounsfield Unit), EB (Epstein - Barr), CMR (cardiac magnetic resonance)

      1. Case report

      A 16-year-old man underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to hemodynamic collapse caused by viral fulminant myocarditis. Supplementary Figure 1 presents the time course of treatment. High-density areas were initially detected by computed tomography (CT) 10 days after admission which was not observed on admission (Fig. 1A). And CT value reached 106 Hounsfield Unit (HU) 40 days after admission (Fig. 1B), the left lateral wall was more evident than other areas. The patient's hemodynamic condition gradually improved and he was discharged 2 months after admission with cardiac function meeting with New York Heart Association class II criteria.
      Fig. 1
      Fig. 1The time course of myocardial calcification on computed tomography (WW: 400HU, WL: 40HU, ST: 7mm). [A] Chest computed tomography (CT) images showing pleural effusion, patch shadows in bilateral lungs, and no morphological abnormalities in the left ventricular wall on admission, [B] CT scan showing high-density areas in the left ventricular wall 40 days after admission, especially in the left lateral wall, [C] Follow-up CT scan 7 months after admission showing extensive ventricular myocardial calcification, [D-E] CT scans I year after admission and 3 years after admission showing gradual regression of calcium deposition in the left ventricular septal and apex wall.
      The patient's myocardial calcification and cardiac function were followed up periodically with CT and echocardiography, respectively. As shown in Supplementary Figure 2, Supplementary Figure 3 the cardiac function remained stable after discharge. And the density of calcification reached the peak (CT value of 142 HU) seven months after admission, followed by a subtle decline (Fig. 1C). Furthermore, the right ventricular calcification almost disappeared at 1-year follow-up (Fig. 1D), while the left ventricular calcification just regressed slightly 3 years after admission (Fig. 1E).

      2. Discussion

      Dystrophic myocardial calcification is a rare but possibly life-threatening complication of viral myocarditis. Dystrophic calcification is the pathological calcification occurred in the ischaemic and injured areas. As in our case, the calcium salts accumulated in the myocardium damaging by inflammatory cytokines released from Epstein–Barr (EB) virus. Additionally, previous reports pointed out that the use of VA-ECMO support and high-dose exogenous glucocorticoids could lead to an imbalance in calcium-phosphate homeostasis.
      • Kapandji N.
      • Redheuil A.
      • Fouret P.
      • et al.
      Extensive myocardial calcification in critically ill patients.
      ,
      • Sato A.Y.
      • Peacock M.
      • Bellido T.
      Glucocorticoid excess in bone and muscle.
      However, serum calcium levels of the patient were always normal or decreased slightly, the exact mechanisms are still unclear. In our case, repeated CT scans manifested a detailed progression of calcium deposition during follow-up. Remarkably, cardiac magnetic resonance (CMR) and echocardiography during follow-up suggested normal left ventricular function although there was massive ventricular calcification, which was different from several prior reports.
      • Nance Jr., J.W.
      • Crane G.M.
      • Halushka M.K.
      • Fishman E.K.
      • Zimmerman S.L.
      Myocardial calcifications: pathophysiology, etiologies, differential diagnoses, and imaging findings.
      ,
      • Lippolis A.
      • Buzzi M.P.
      • Romano I.J.
      • Dadone V.
      • Gentile F.
      Stone heart: an unusual case of heart failure with preserved ejection fraction due to massive myocardial calcification.
      Perhaps it is linked with a timely and effective comprehensive treatment regimen. The exact mechanisms still need further investigation.
      In conclusion, myocardial calcification can progress over time and is probably not a marker of a pathologic process that influences cardiac function. Our reports underline the importance of early intervention, efficient management in patients, and the utility of CT which plays a key role in thoroughly managing and evaluating the prognosis of patients with myocardial calcification secondary to viral myocarditis.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of competing interest

      All authors declare no conflict of interest.

      Acknowledgements

      We are grateful to all the group mates and their parents in the hospital.

      Appendix A. Supplementary data

      The following is/are the supplementary data to this article:

      References

        • Kapandji N.
        • Redheuil A.
        • Fouret P.
        • et al.
        Extensive myocardial calcification in critically ill patients.
        Crit Care Med. 2018; 46: e702-e706
        • Sato A.Y.
        • Peacock M.
        • Bellido T.
        Glucocorticoid excess in bone and muscle.
        Clin Rev Bone Miner Metabol. 2018; 16: 33-47
        • Nance Jr., J.W.
        • Crane G.M.
        • Halushka M.K.
        • Fishman E.K.
        • Zimmerman S.L.
        Myocardial calcifications: pathophysiology, etiologies, differential diagnoses, and imaging findings.
        J Cardiovasc Comput Tomogr. 2015; 9: 58-67
        • Lippolis A.
        • Buzzi M.P.
        • Romano I.J.
        • Dadone V.
        • Gentile F.
        Stone heart: an unusual case of heart failure with preserved ejection fraction due to massive myocardial calcification.
        J Cardiol Cases. 2021; 23: 145-148