Myocarditis, hepatitis, and pancreatitis in a patient with coxsackievirus A4 infection: a case report

Abstract

Viral myocarditis presents with various symptoms, including fatal arrhythmia and cardiogenic shock, and may develop chronic myocarditis and dilated cardiomyopathy in some patients. We report here a case of viral myocarditis with liver dysfunction and pancreatitis. A 63-year-old man was admitted to our hospital with dyspnea. The initial investigation showed pulmonary congestion, complete atrioventricular block, left ventricular dysfunction, elevated serum troponin I, and elevated liver enzyme levels. He developed pancreatitis five days after admission. Further investigation revealed a high antibody titer against coxsackievirus A4. The patient’s left ventricular dysfunction, pancreatitis, and liver dysfunction had resolved by day 14, but his troponin I levels remained high, and an endomyocardial biopsy showed T-lymphocyte infiltration of the myocardium, confirming acute myocarditis. The patient underwent radical low anterior resection five weeks after admission for advanced rectal cancer found incidentally. His serum troponin I and plasma brain natriuretic peptide levels normalized six months after admission. He has now been followed-up for two years, and his left ventricular ejection fraction is stable.This is the first report of an adult with myocarditis and pancreatitis attributed to coxsackievirus A4. Combined myocarditis and pancreatitis arising from coxsackievirus infection is rare. This patient’s clinical course suggests that changes in his immune response associated with his rectal cancer contributed to the amelioration of his viral myocarditis.

Pancreatitis and myocarditis coexistence due to infection by Coxsackie B1 and B4 viruses

“…Viral myocarditis is important because as it can cause both mechanical dysfunction and electrical abnormalities leading to ventricular arrhythmias that are potentially life‐threatening. To the best of our knowledge, there are three previously reported cases of adult patients with myocarditis and pancreatitis attributable to Coxsackie virus infection with serotypes A4, B2, B4, and B5 being implicated . An interesting finding in experimental models was the etiologic link between group B Coxsackie‐induced pancreatic and heart disease .…”

Effusive-constrictive pericarditis, hepatitis, and pancreatitis in a patient with possible coxsackievirus B infection: a case report

“…The combination of myocarditis, hepatitis and pancreatitis due to coxsackie B infection is very rare. Two such reported cases were attributed to coxsackie A4 and B2 serotypes [ 14 , 15 ]. The disease process of acute pericarditis can progress to a large pericardial effusion that can cause cardiac tamponade.…”

“…In a separate study, only 4.3 % of patients with acute pancreatitis exhibited significant rising antibody titers to coxsackie B virus [ 11 ]. The combination of myocarditis and pancreatitis from coxsackievirus is few and far between given that the rate of asymptomatic pancreatitis may be higher than previously thought in infected patients with myocardial involvement [ 14 ].…”

“…Constrictive pericarditis with effusion has been detected in ten percent of patients with clinical tamponade [ 2 ]. Coxsackie B viruses usually cause various single organ system diseases, but the combination of myocarditis, pancreatitis and hepatitis has been documented in two case reports [ 14 , 15 ]. Herein, we report a case of possible coxsackievirus B infection causing effusive-constrictive pericarditis, hepatitis and pancreatitis.…”

Acute Viral Hepatitis E Is Associated with the Development of Myocarditis

“…Among the latter, HCV RNA was detected in 13 hearts (21.3%) and negative strands were detected in 4 hearts (6.6%). HCV RNA was found in 4 hearts (33.3%) with myocarditis, in 3 hearts (11.5%) with dilated cardiomyopathy, and in 6 hearts (26.0%) with hypertrophic cardiomyopathy [ 22 , 23 ].…”