Myocarditis Presenting as Diabetic Ketoacidosis
Alex Tatusov, MD, Scott Feitell, DO, Syed Farhan Hasni, MD
Hahnemann University Hospital-Drexel University College of Medicine Philadelphia, PA
Learning Objectives
• To help diagnose and treat myocarditis
• To establish a link between myocarditis and
diabetic ketoacidosis
Background
• Myocarditis is an inflammatory disease of the
cardiac muscle
• Presentation is one of acute heart failure, acute
myocardial infarction or pleuritic chest pain
• Viruses are the most frequent pathogens with
coxsackie virus considered one of the most common
Case Presentation Continued
On hospital day 5, troponins peaked at 34.6. The
patient developed shortness of breath, orthopnea,
and lower extremity edema. Chest x-ray revealed
bilateral pleural effusions and pulmonary edema.
Coxsackie titers came back positive in serum and
cerebrospinal fluid. All blood and sputum cultures
remained negative. The patient was diagnosed with
viral myocarditis and treated with Lasix, Metoprolol
and Lisinopril. Her symptoms improved and she was
eventually discharged on hospital day 11.
Table 1. Cardiac enzyme measurement during
the hospitalization
Case Presentation
CC: Cough, sore throat, confusion
Hospital Course: 18 year old African American
female with past medical history of type 1 diabetes
presented to the hospital with four days of cough,
sore throat, and increasing confusion. Initial physical
exam revealed tachycardia, tachypnea, lethargy and
dry mucous membranes. Lungs were clear to
auscultation. There was no increased jugular venous
distention, S3, or lower extremity edema.
Laboratory findings showed a white blood cell count
of 28, glucose of 686, anion gap of 22, a pH of 7.02
on an arterial blood gas and a urinalysis positive for
ketones. Initial electrocardiogram (EKG) showed sinus
tachycardia without ischemic changes. The patient
was diagnosed with DKA and treated with intravenous
insulin and intravenous fluids. The following day
cardiac monitoring showed ST elevations in inferior
and lateral leads. Cardiac enzymes revealed a
troponin of 11.9. Echocardiography was limited by
patients’ body habitus but showed apical wall motion
abnormality.
RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
Figure 2. Prognosis in myocarditis can be highly
variable ranging from self limited disease of
varying severity to progressive disease
Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
CK
CKMB
cTnI
1048 1538 1134
948
471
405
428
64.5 127.2 116.2 93.1
16.1
3.8
3.5
34.6 16.87 16.3
1.79
1.0
11.9
26.5
19.2
Figure 1. EKG showing ST elevations in inferior
and lateral leads
Discussion
The diagnosis of myocarditis is often difficult due to
lack of established non invasive “gold standard”.
Even the Dallas criteria that relies on an
endomyocardial biopsy has a sensitivity of only 1035%. DKA is rarely associated with myocarditis. In a
few cases that have been reported the metabolic
disturbance always seems to precede myocardial
damage. The present case further highlights DKA as
a rare but clinically significant presentation of
myocarditis.
References
1. Smith SC. Elevations of Cardiac Troponin I Associated With
Myocarditis. Circulation.1997, 95: 163-168
2. Cooper LT Jr. Natural History and Therapy of Myocarditis in
Adults. In: UpToDate, 2012.
3. Miklozek CL. Serial Cardiac Function Tests in Myocarditis.
Postgraduate Medical Journal 1986, 62:577-579
4. Grogan M., et al. Long-Term Outcome of Patients with
Biopsy-Proved Myocarditis: Comparison with Idiopathic
Cardiomyopathy. Journal of the American College of
Cardiology. 1995, 26(1):80-84.