Abstract 4144743: From Tummy Trouble to Heart Hassle: A Case of Traveler's Diarrhea Triggering Myopericarditis

Case description: >A 38-year-old male with a history of paroxysmal atrial fibrillation status post-RFA ablation, presented to the emergency department (ED) with a 3-week history of non-bloody diarrhea, abdominal cramping, nausea, fever, and headache after a trip to Guatemala. In the ED, his vital signs were temperature (99.3 °F), and heart rate (116 bpm). Notable physical exam findings were diffuse erythematous macular rash and conjunctival injection. Initial labs demonstrated elevated white count (15,100 K/mcL) and lactate (3.2 mmol/L). He was treated with ceftriaxone and metronidazole, with clinical improvement. Stool cultures were positive for salmonella and cyclospora cayetanensis. On hospital day 3, he developed severe substernal chest pain, minimal ST elevation in the anterolateral leads on ECG and elevated HS- troponin levels of 7000 ng/ml, peak of 12000 ng/ml. Transthoracic echocardiogram showed normal LV systolic function, with no evidence of pericardial effusion and regional wall motion abnormalities. Subsequent cardiac MRI demonstrated evidence of myopericarditis(anterior and lateral pericardial enhancement, along with focal epicardial late gadolinium enhancement in the mid inferolateral wall of the left ventricle with associated myocardial edema, and a small pericardial effusion). He was discharged home on Trimethoprim-Sulfamethoxazole and started on colchicine, with no recurrent chest pain. Discussion: Myopericarditis is a complication of acute pericarditis due to pericardial inflammation extension to the myocardium. It is usually caused by a virus and rarely due to bacteria as demonstrated by this case, presenting as elevated troponin levels and ST-segment elevation on ECG. To our knowledge, there are no known reports of cyclospora cayetanensis causing myopericarditis. The adherence of the salmonella bacteria to the cardiac endothelium can result in myocyte necrosis and release of self-antigens leading to the development of antibodies and autoimmune myocarditis. Long-term management of bacterial myopericarditis is dependent on the severity of the clinical presentation and includes antibiotics, anti-inflammatory medications, and colchicine. Most patients recover within one month, but persistent cardiac dysfunction and progression to end-stage dilated cardiomyopathy can occur, thus follow-up echocardiography is recommended.