A 20-year-old African American male presented with a chief complaint of chest pain. He was asymptomatic until 1 week prior to admission when he developed a headache and neck ache, nausea, rash, and fever. Two days prior to admission he experienced the sudden onset of squeezing, left-sided chest pain that was nonradiating, exacerbated by lying supine, and improved by sitting upright. He denied shortness of breath but did complain of a dry cough and increasing fatigue with exertion. Lung examination revealed diffuse rhonchi and bibasilar crackles and cardiac auscultation demonstrated an S3 gallop. There were erythematous, papular plaques and patches over his trunk and proximal upper and lower extremities bilaterally. Laboratory evaluation revealed WBC count of 10,400 with 29% bands, platelets of 120,000, AST 169, ALT 63, CPK 1,955, CKMB 153, and troponin I 31.5. His ECG demonstrated global ST elevation and a transthoracic echocardiogram (TTE) revealed an ejection fraction of 15% without evidence of pericardial effusion. Blood cultures, HIV ELISA, HIV PCR, ANA, anti-double-stranded DNA, and West Nile virus, ehrlichia, and RMSF serologies were negative. CSF analysis revealed no RBC or WBC, glucose 72, protein 19, and negative cryptococcal antigen, gram stain, and culture, West Nile IgM, and HSV DNA PCR. He was treated for a presumed viral myopericarditis with Lasix, Lisinopril, Toradol, and Solu-Medrol 40 mg IV every 12 hours. Within 4 days of starting treatment he became afebrile, his headache and neck ache subsided, and his rash and S3 gallop disappeared. His AST and ALT were 36 and 111, respectively, and his platelets rose to 356,000. His CPK was 50, CKMB 1.8, and troponin I 1.73. A repeat TTE revealed a normal heart with an ejection fraction of 55%. Viral infection is the most common cause of myocarditis in developed countries. A reliable, noninvasive diagnostic test for viral myocarditis does not exist. While the presence of a prodrome can aid in the diagnosis of viral myocarditis, it is usually a diagnosis of exclusion, made when all other tests have been unrevealing. Currently, based on small, controlled trials, steroids are not part of the standard of care for these patients. However, our patient made a rapid and complete recovery on intravenous steroids, suggesting a possible role for their use in certain patients with viral myocarditis. Further large, controlled studies should be done to reexamine the effectiveness of steroids in the treatment of viral myocarditis in selected patients.
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