Epstein- Barr associated acute myocarditis: A rare culprit with potentially fatal outcomes

Presenting Author(s)

• 

  Noura Ahmed

  Cardiac MRI post CCT fellow
  CMR Unit - Bristol Heart Institute
  Bristol, England, United Kingdom

Primary Author(s)

• 

  Noura Ahmed

  Cardiac MRI post CCT fellow
  CMR Unit - Bristol Heart Institute
  Bristol, England, United Kingdom

Co-Author(s)

• FG

  Fabio Greco

  Consultant Radiologist
  CMR Unit - Bristol Heart Institute, United Kingdom
• EM

  Efstathios Magkiosis

  Cardiac MRI fellow
  CMR Unit - Bristol Heart Institute, United Kingdom
• OT

  Omar Tawfik

  Clinical fellow
  Bristol Heart Institute
  Bristol, United Kingdom
• SK

  Sameh Khalil

  Cardiac MRI fellow
  CMR Unit - Bristol Heart Institute
  Bristol, United Kingdom
• IH

  Iwan Harries, PhD

  Cardiology consultant
  Bristol Heart Institute
  Bristol, United Kingdom
• ES

  Eva Sammut

  Consultant Cardiologist
  Bristol Heart Institute
  Bristol, United Kingdom
• MH

  Mark Hamilton

  Consultant Cardiac Radiologist
  Bristol Heart Institute, United Kingdom
• GS

  Gergely V. Szantho, MD

  Consultant Cardiologist
  Bristol Heart Institute
  Bristol, United Kingdom
• SV

  Sharareh Vahabi, MD

  Consultant cardiologist
  CMR Unit - Bristol Heart Institute
  Bristol, United Kingdom
• AI

  Abdalazeem Ibrahem

  Consultant cardiologist
  North Bristol NHS trust, United Kingdom
• Pc

  Paul cundick

  Cardiac MRI radiographer
  CMR Unit - Bristol Heart Institute, United Kingdom
• DB

  Daniel Burden

  Cardiac MRI radiographer
  CMR Unit - Bristol Heart Institute, United Kingdom
• SW

  Simon Whigham

  Radiographers superintendent
  CMR Unit - Bristol Heart Institute, United Kingdom
• PS

  Praveen Subramanian

  Cardiac MRI radiographer
  CMR Unit - Bristol Heart Institute, United Kingdom
• RJ

  Rabeia Javid, BSc, MB

  Cardiology Registrar
  University of Leeds
  Bradford, England, United Kingdom
• LM

  Lisa Mcclenaghan

  Consultant cardiologist
  CMR Unit - Bristol Heart Institute, United Kingdom
• CB

  Christina Botrous

  Specialty Registrar Cardiology
  CMR Unit - Bristol Heart Institute, United Kingdom
• RT

  Raluca Tomoaia

  Cardiology consultant
  University of Leeds, United Kingdom
• BC

  Benjamin Corden

  Consultant cardiologist
  CMR Unit - Bristol Heart Institute, United Kingdom

Description of Clinical Presentation: 20 years old male

Presented to the Emergency Department with 3 day history of acute chest pain, sharp worse with inspiration and improved with leaning forward. Associated with episodes of fever and chills, dry cough, malaise, headache, loss of appetite, nausea and vomiting.

Background previous acute pericarditis in 2017 and acute myocarditis in 2022. History of vaping and cocaine use (stopped 2 years ago), non-smoker and no alcohol consumption. No family history of cardiovascular disease. Physical examination showed a low BMI of 16 Kg/m2 but otherwise unremarkable.

Initial investigations on admission:ECG normal sinus rhythm and T-wave inversion in aVL. Transthoracic echocardiogram from 2025 showed no regional wall motion abnormalities and reduced left ventricular ejection fraction at 45%. Troponin I ( Normal range < 18 ng/L) 2944, 9256 and 6431 ( previous Troponin I in 2022 was 256 ).
Normal full blood count, renal function and liver function. CRP was elevated at 160 mg/l. Negative blood cultures. Negative autoimmune screen. All virology screen was negative except for positive Epstein Barr IgG and IgM antibodies. Normal chest X ray.

Management: Initially he was started on heart failure therapy: beta-adrenergic blockers and angiotensin-converting enzyme inhibitors. He was also advised to stop exercise.

He was referred for cardiac MRI to assess for myocarditis.

Diagnostic Techniques and Their Most Important Findings: Oedema protocol was used in a Siemens’s 1.5 T scanner. With the following sequences and findings:
1. Localisers: No pericardial effusion.
2. Cine 4 chambers, 2 chambers, 3 chambers and short axis: All showed normal morphology, size and normal biventricular function. LVEF 58% and RVEF 60%.
3. Late gadolinium enhancement:
Patchy / confluent subepicardial / mid myocardial diffuse near circumferential late gadolinium enhancement with partial sparing of the septum.
4. Native T1 maps: Elevated global and regional T1 values corresponding to the same area of late gadolinium enhancement.
5. T2 maps: Elevated global and regional T2 values corresponding to the same area of late gadolinium enhancement.
In summary CMR showed a diffuse and extensive non infarct pattern circumferential subepicardial and mid myocardial fibrosis in all basal to mid segments.
Thus, given myocardial oedema, extensive scarring, history of recurrent episodes of myocardial/pericardial inflammation and positive Epstein Barr virus serology, this presentation represents Epstein Barr associated acute myocarditis.

Learning Points from this Case: Epstein Barr associated acute myocarditis is rare and contributes to only 1% of cases. It requires a high index of suspicion. There have been case reports of mortality secondary to EBV due to complete heart block, ventricular anrrhythmias and sudden cardiac death. This is particularly important in young patients presenting with recurrent myocarditis. Hence, the importance of early recognition and treatment with immunosuppression which could be life-saving.

Short axis late gadolinium enhancement
4 chamber late gadolinium enhancement
Short axis T2 maps