A Case of Recurrent Myopericarditis

A 26 year-old male with a history of viral myopericarditis one year prior presented to cardiology clinic for a follow-up visit. The patient was a recreational athlete who had been playing full-court basketball with a league five to six times a week for many years. One year prior to this index presentation, he had presented to the emergency department with three days of mid-sternal chest pain relieved by leaning forward. His symptoms began one week after an upper respiratory tract infection. His electrocardiogram (ECG) was notable for left ventricular hypertrophy with early repolarization, and his initial troponin T was 0.406 ng/mL. An echocardiogram was unremarkable. His troponin downtrended to 0.380 ng/mL the following day. He was seen by cardiology who felt his presentation was consistent with mild viral myopericarditis, and recommended activity restriction along with close follow-up. He was discharged on a regimen of high-dose ibuprofen for two weeks, along with daily colchicine 0.6mg for three months. His symptoms quickly resolved. Six months later, after labwork confirmed normalization of inflammatory biomarkers, he underwent a maximal-exercise ECG treadmill stress test which was unremarkable. He was permitted to return to playing moderate to high intensity recreational basketball at that time.

Three months later, he presented to a different emergency department after a 10-day history of an upper respiratory tract infection. He described a subacute onset of chest pain and dyspnea during that time, similar to his symptoms nine months prior, but more intense in nature. An ECG was reportedly unremarkable, however an initial troponin I was markedly elevated at 20 ng/mL. He was admitted and underwent further testing with an echocardiogram and coronary computed tomography angiography (CTA), both of which were normal. A basic rheumatologic workup was also unrevealing. His chest discomfort improved with the initiation of colchicine and high dose ibuprofen, and his troponin I downtrended to 15 ng/mL on the day of discharge. He was again advised to restrict his physical activity to only low exertion. Two weeks later he presented to clinic for follow-up evaluation.

At this index visit, he reported complete resolution of his symptoms and adherence to low activity restriction. Vital signs were within normal limits. Physical exam revealed clear lungs, a normal jugular venous pulsation, and a regular cardiac rhythm, without any murmurs, rubs or gallops. His extremities were warm without any edema. An ECG again showed left ventricular hypertrophy without additional abnormal findings. Labwork at this visit showed normal chemistries and a complete blood count, as well as normal inflammatory markers. Cardiac magnetic resonance imaging (MRI) was obtained; demonstrative cine and sequential delayed gadolinium enhancement (DGE) images are shown in Videos 1 and 2.

Video 1 – Cine

Figure 1

Video 2 – Axial Stack Sequence

Based on the MRI findings, what is the next best step in management?

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