Cardiac magnetic resonance in a rare case of recurrent mesalazine-induced myocarditis.

Mesalazine represents a key treatment for intestinal bowel diseases and only in rare cases produces cardiac toxicity, with a not completely known mechanism. We report a case of a 25-year-old man with a first episode of myocarditis after 2 weeks from the first mesalazine intake, documented also by a characteristic cardiac magnetic resonance pattern. Then, after less than 1 month, he suffered myocarditis recurrence and so, guided by a multidisciplinary team evaluation, in the suspicion of mesalazine-induced myocarditis, the drug was promptly stopped, with consequent recovery of cardiac damage. In our patient, the recurrence of myocarditis because of the non-interruption of the drug is very peculiar (only three cases described in literature) and definitively confirms the diagnosis.

This paper reports an exemplary case of cardiac toxicity induced by mesalazine, a key treatment for inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. In rare cases, this drug can lead to cardiac impairment, with a mechanism not yet clarified. The young patient described experiencing a first episode of myocarditis (inflammation of the heart muscle cells) after 2 weeks of starting mesalazine. The diagnosis was possible thanks to cardiac magnetic resonance, a noninvasive exam providing high-definition images associated with tissue characterization. Mesalazine was not discontinued because drug-induced etiology was not suspected, due to its rarity. Consequently, the patient suffered a second episode of myocarditis, diagnosed by endomyocardial biopsy, an invasive technique that can accurately assess the etiology of myocardial damage, leading to prompt cessation of treatment. Since myocarditis can have various causes, diagnosis was also facilitated through a multidisciplinary team, which ruled out other possible causes for this condition. This case report is highly educational and underscores the importance of clinicians being vigilant about this side effect and considering it in patients taking mesalazine who present with myocarditis, to promptly discontinue the treatment. Mesalazine interruption is otherwise the only effective therapy for this condition, in addition to anti-inflammatory and analgesic drugs. Furthermore, this paper highlights the increasing importance of multidisciplinary teams, comprising various specialists, for accurate diagnosis and therapeutic decisions. The authors also propose an algorithm for diagnosing mesalazine-induced myocarditis, with certainty derived from recurrence after drug rechallenge, either voluntarily or accidentally, as demonstrated in this case.

Effectiveness of levosimendan and role of cardiac magnetic resonance in cardiogenic shock due to COVID-19 related lymphocytic myocarditis in the course of viral sepsis.

COVID-19 and sepsis pose great challenges to clinicians and growing evidence is demonstrating links between the two conditions. Both can be complicated by acute heart failure. The use of levosimendan in patients with ventricular dysfunction during COVID-19 infection and sepsis has very little evidence. A 46-year-old, hypertensive and obese patient was admitted for severe left ventricular failure and shock during sepsis following a COVID-19 infection. The patient was treated first with norepinephrine, which was partially effective, then with the addition of levosimendan as a continuous 24 hours infusion. Vital signs and echocardiographic systolic performance indices, such as FE, SVi, CI, dP/dT, TAPSE, and tricuspid S-wave velocity, as well as diastolic function, were recorded at access, 12 and 24 hours. After initiation of levosimendan, a rapid improvement in vital signs and systolic and diastolic performance indices was observed, not depending on changes in preload, afterload, and inflammatory status. Blood cultures were negative for the presence of bacteria, thus defining the picture of likely viral sepsis. Cardiac magnetic resonance was determinant, showing a picture of myocarditis sustained by immune processes rather than direct viral injury, which was confirmed by endomyocardial biopsy. In conclusion, this case highlights the efficacy of levosimendan in acute heart failure complicated by shock due to COVID-19-related myocarditis and concomitant sepsis and confirms cardiac magnetic resonance as the gold standard for the diagnosis of myocardial inflammatory disease. To the best of our knowledge, this is the first documented case of effective use of levosimendan in this context.

Accordion sign in COVID 19 related acute myocarditis, an old sign for a novel context? A cardiac magnetic resonance case series report study.

INTRODUCTION: The COVID-19 pandemic is related to a higher incidence of myocarditis; we present a case series of seven patients, admitted with COVID-19 related acute myocarditis, evaluated with cardiac magnetic resonance imaging, showing an altered profile of the free wall of the right ventricle, no longer present after six months follow-up. MATERIALS AND METHODS: Seven patients have been evaluated for COVID-19 related acute myocarditis, all patients have been evaluated with cardiac magnetic resonance imaging both in the acute setting and after six months follow-up. RESULTS: In the acute phase, myocarditis was confirmed in keeping with the current diagnostic criteria. In five out of seven cases, the presence of a crinkling profile of the free wall of the right ventricle was observed; at six months follow up, remission in four out of the five cases and a significant reduction in the remaining case, of the previously described findings, was observed. CONCLUSIONS: Crinkling appearance in the profile of the free wall of the right ventricle, detectable with cardiac magnetic resonance imaging, might represent a morphological feature present in the acute setting of COVID-19 related myocarditis; several underlying physiopathological mechanisms are conceivable. Further studies are needed to confirm this correlation, define the underlying mechanisms and the prognostic implication related to it. This is the first report in the literature that has considered such findings to the best of our knowledge.

When it's neighbor's fault, a complicated ascending aortic aneurysm mimicking pulmonary embolism: A case report.

Thoracic aortic aneurysms represent a potentially life-threatening disease with increasing prevalence, probably related to the increasing mean age of the global population; the complications of thoracic aortic aneurysms can show multiple modes of presentation in the acute phase based on various factors, including the involvement of the structures with which the aneurysm is in close anatomical relationship. With this case report we want to show how it is possible that a complicated ascending aortic aneurysm can mimic an acute pulmonary embolism/acute cor pulmonale in the acute phase; the earliest possible differential diagnosis between pulmonary embolism and acute aortic disease is of crucial importance due to the opposite implications that the treatment of these two diseases have. .

Tricuspid annular disjunction can be isolated and even arrhythmogenic. A cardiac magnetic resonance study.

Mitral annular disjunction is related to increased arrhythmogenic risk; in a certain percentage of cases, mitral annular disjunction is associated with tricuspid annular disjunction. While the prognostic implications of mitral annular disjunction have been well established, there is still little data to define this aspect regarding the tricuspid annular disjunction. We present a case of a patient admitted for life-threatening ventricular arrhythmias that occurred during endurance sporting activity, who was found to have isolated tricuspid annular disjunction, not associated with mitral annular disjunction. Based on several factors, including the morphology and axis of QRS of the ventricular arrhythmic activity, and its behavior, including the response to antiarrhythmic treatment, and in keeping with the finding of edema and late gadolinium enhancement at the basal segment of the right ventricle free wall on cardiac magnetic resonance imaging, a direct relation between tricuspid annular disjunction and ventricular arrhythmias was highly conceivable. Control after three months showed almost complete remission of the previously described and persistence of LGE at the level of the basal segment of the free wall of the right ventricle, so giving strength to the hypothesis of an event related to increased acute RV free wall stress, secondary to high-intensity physical activity, established on a framework of chronic wall stress, as represented by LGE, similarly to what happens for mitral valve prolapse. To the best of our knowledge, this is the first case of a legitimately conceivable direct relation between tricuspid annular disjunction and ventricular arrhythmias.

Multislice CT in the study of insulinomas: preliminary experience.

PURPOSE: To evaluate the potential of Multislice Computed Tomography (MSCT) in the study of pancreatic insulinomas. MATERIALS AND METHODS: Three patients with a suspected insulinoma underwent MSCT. All patients presented clinical and laboratory evidence of insulin secretive neoplasm. In all cases unenhanced and enhanced scans were performed. The enhanced scans were obtained after the injection of 2 ml/kg of non ionic contrast medium at a flow rate of 4 ml/sec with a scan delay of 35 and 55 sec. All the images were reformatted using MPR and MIP algorithms. RESULTS: In the three patients, CT showed the presence of an insulinoma (in two cases the neoplasm was sited in the head of the pancreas, in one case in the body). In two of the patients, MPR and MIP images did not add any diagnostic information. In one case, MIP and MPR reconstructions facilitated the diagnosis with a better depiction of anatomic relations between the lesion and pancreatic vessels. CONCLUSIONS: MSCT, in our limited experience, demonstrated good potential in the evaluation of insulinomas. MPR and MIP help in the evaluation of anatomic relations between lesions and vascular structures.