Mesalamine-induced myocarditis following diagnosis of Crohn's disease: A case report

Abstract

Mesalamine is a common treatment for Crohn's disease, and can be rarely associated with myocarditis through a mechanism of drug hypersensitivity. We present the case of a 19-year-old male who developed chest pain two weeks after beginning mesalamine therapy. The electrocardiogram showed slight ST-segment elevation with upward concavity in the inferolateral leads; blood tests demonstrated elevated troponin I and the echocardiogram revealed moderately depressed left ventricular systolic function with global hypocontractility. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis, revealing multiple areas of subepicardial fibrosis. The onset of symptoms after mesalamine, and improvement of chest pain, cardiac biomarkers and left ventricular systolic function after discontinuing the drug, suggest that our patient suffered from a rare drug-hypersensitivity reaction to mesalamine. © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved. PALAVRAS-CHAVEMiocardite; Mesalamina; Ecocardiografia transtorácica; Ressonância magnética cardíaca Miocardite induzida pela mesalamina após o diagnóstico de doença de Crohn ---relato de um caso clínico Resumo A mesalamina é um tratamento comum para a doença de Crohn, associando-se de forma rara à miocardite aguda, através de uma reação de hipersensibilidade ao fármaco. Os autores apresentam o caso clínico de um jovem de 19 anos com aparecimento de dor torá-cica duas semanas após ter iniciado tratamento com mesalamina para a doença de Crohn. O eletrocardiograma mostrou um discreto supradesnivelamento do segmento ST, de concavidade ascendente, nas derivações infero-laterais; as análises revelaram elevação da troponina I e o ecocardiograma exibiu uma depressão moderada da função sistólica do ventrículo esquerdo, por hipocontractilidade global. A ressonância magnética cardíaca confirmou o diagnóstico de miocardite, evidenciando múltiplas áreas de fibrose subepicárdica. O início dos sintomas após o começo da mesalamina e a melhoria da dor torácica, biomarcadores cardíacos e função sistólica * Corresponding author. E-mail address: carlos.galvaobraga@gmail.com (C. Galvão Braga).0870-2551/$ -see front matter © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved. http://dx.doi.org/10.1016/j.repc.2012.12.018 Document downloaded from http://http://www.elsevier.pt, day 14/02/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 718C. Galvão Braga et al. ventricular esquerda após a suspensão do medicamento, sugerem que o nosso paciente teve uma reação rara de hipersensibilidade à mesalamina.

Cardiac MRI-confirmed mesalamine-induced myocarditis

“…Hash shading represents affected area. (A) Patchy, mid-myocardial enhancement in posterior wall and inferior interventricular septum (present case); (B) Subepicardial enhancement in anterior wall and transmural extension in interventricular septum; also in the interatrial septum (not shown);3 (C) Subepicardial enhancement in apical inferior wall and transmural enhancement in interventricular septum;4 (D) Subepicardial enhancement in inferior and lateral walls 2…”

“…The exact mechanism for mesalamine-induced myocarditis is not well established;4 however, patients typically present with symptoms within 2–4 weeks after initiation (sometimes delayed when corticosteroids are used concurrently) 2. Common signs and symptoms of mesalamine-induced myocarditis include substernal chest pain, dyspnoea, fever, leucocytosis, elevated cardiac enzymes and inflammatory markers, T-wave or ST-segment abnormalities (T-wave flattening is particularly common) and LVSD 1.…”