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.

Myocarditis Secondary to Mesalamine-Induced Cardiotoxicity in a Patient with Ulcerative Colitis

“…IBD may also affect a variety of extraintestinal organs such as integumentary, musculoskeletal, and pulmonary organs. Extraintestinal manifestations are common and occur in approximately 25–30% of patients although cardiac involvement is rare [ 1 – 3 ]. Manifestations of cardiac involvement include pericarditis, myocarditis, and myopericarditis.…”

“…An additional side effect of mesalamine that has not been extensively described in literature is cardiotoxicity. The drug can cause pericarditis, myocarditis, and coronary vasculitis [ 3 ]. The specific mechanism of mesalamine-induced cardiotoxicity is yet to be described, but several hypotheses have been proposed.…”

“…This leads to the overproduction of eosinophil-stimulating cytokines thereby initiating a hypersensitivity reaction [ 4 ]. Another proposed mechanism involves humoral-mediated hypersensitivity, in which antibodies formed against mesalamine cross react with cardiac tissues causing inflammation [ 1 , 3 ]. Other hypothesized mechanisms include a direct toxic effect of mesalamine on the myopericardium, a cell-mediated hypersensitive reaction, and an allergic reaction mediated by immunoglobulin E [ 4 , 5 ].…”

Mesalazine-Induced Myopericarditis in a Patient with a Recent Diagnosis of Crohn’s Disease: Apropos of a Case

“…Several cases were described in the literature. Resolution of symptoms has occurred in all reported cases within one week after drug discontinuation [ 5 – 8 ]. Although the precise pathophysiology of mesalazine-induced myopericarditis is poorly understood, it is thought to be a hypersensitivity reaction rather than a cytotoxic effect.…”

Five-Aminosalicylic Acid: An Update for the Reappraisal of an Old Drug

“…Cardiac disease may develop in Crohn's patients either as a disease extraintestinal manifestation or as an adverse reaction to 5-ASA therapy. Such occurrence is well reported and documented, with several cases described in literature reports [ 54 , 94 – 100 ]. 5-ASA-associated myocarditis is a rare but potentially life-threatening manifestation, generally occurring 2–4 weeks after the initial exposure to the drug [ 94 ].…”