10 Case 3-2020: Answers to the questions

Question 1: Based on the ECG, what cardiac biomarkers should we examine for this patient? What would they tell us?

Answer to Question 1: The patient is hypertensive and ECG shows T inversion in lead II, III, and aVF so, we should look for cardiac biomarker troponin I, Troponin T, CK-MB. These markers were elevated in the patient.  

    • Serum Tn I: 2.57 ng/mL (normal range: 0-0.034 ng/mL),
    • Troponin T: 34.34 pg/mL (normal range : 3-14 pg/mL).
    • Creatine kinase isozyme (CK-MB): 11.85 ng/mL (normal range: 0.1-4.94 ng/mL)

Considering the patient’s symptoms of chest pain, elevated cardiac biomarker (troponin T and I), and ECG findings (T inversion), all these findings indicate myocardial infarction.5

Question 2: What is the purpose of IgG and IgM antibody analysis? 

Answer to Question 2: Lab investigations had revealed elevated C-reactive protein of 4.95 mg/L (normal range 0-2.87 mg/L)1 and an erythrocyte sedimentation rate (ESR) of 45mm/h, together, indicative of infection.  

    • Further analysis would reveal elevated levels of IgG and IgM antibodies. In the literature, IgM antibodies have been linked to recent infections, while IgG antibodies reveal the presence of recent or previous infections.11
Question 3: Which tests were performed to confirm the diagnosis? How can we interpret these results? 

Answer to Question 3:

  • To confirm the diagnosis, cardiovascular resonance imaging was used to reveal an anterior ventricular wall thickness of 20.38mm (normal walls 12mm), while FS-T2WI results showed edema. Rubella IgG and IgM antibody levels were elevated. Based on these results, the confirmatory diagnosis is viral myocarditis. 1

 

Diagnosis 1

  • Patient symptoms and elevated cardiac biomarker with ECG findings indicate myocardial infarction.
  • Based on CMR imaging findings and elevated rubella IgG and IgM antibody confirmatory diagnosis is viral myocarditis.

Treatment and Prognosis1

  • Treatment: Aspirin, clopidogrel, acyclovir(antiviral), levofloxacin (antibiotic).
  • Prognosis:
    • 10 months later: The patient was asymptomatic. ECG: normal, echocardiography: normal with patchy enhancement in the ventricular septal wall. CMR: edema disappears ventricular wall thickness 14mm (as the patient is hypertensive so high BP leads to ventricular hypertrophy).

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This post is adapted for the Health & Medical Case Studies created by the Master of Medical Biotechnology program of the University of Windsor. This work licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC-ND) 4.0 International License.

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HEALTH & MEDICAL CASE STUDIES (V1.01) Copyright © by Dr. Tranum Kaur is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

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