Sepsis-Related Myocardial Calcification

Abstract

A 56-year-old man was admitted on our intensive care unit with septic shock after 10 days of diarrhea, shortly after he had visited India. He had no relevant previous medical history. Blood and fecal cultures grew various pathogens, including Shigella flexneri. ECG showed diffuse ST elevation with PR depression (Figure 1), and laboratory results revealed significant troponin (peak level of 5.72 ng/mL) and creatine phosphokinase-MB (peak level of 117 ng/mL) release, most likely caused by a perimyocarditis in the setting of Shigella sepsis. Further diagnostic evaluation revealed hairy cell leukemia. After initial improvement of his clinical condition and treatment with rituximab and prednisolone, he was readmitted to the intensive care unit with respiratory failure and new-onset left ventricular dysfunction as was observed with echocardiography. Compared with the prior tracing, his ECG now showed microvoltages in the extremity leads, this time with normal ST segments ( Figure 2). Computed tomographic imaging revealed extensive myocardial calcification of the left ventricle that was not seen on previous computed tomographic images (Figures 3 and 4). Comparable images of a pronounced dense myocardium with normal aspect of the endocardial layer were observed with transesophageal echocardiography (Figure 5). Serum levels of calcium were repeatedly not elevated during the admittance.Localized myocardial calcification is commonly observed after myocardial infarction. Diffuse calcification, however, is a rare phenomenon. Interestingly, similar cases of extensive left ventricular calcification after a period of severe sepsis have been described previously. 1-3 Two different pathophysiological mechanisms resulting in calcium deposition in cardiac myocytes can be distinguished. 4 First, significant disturbances in calcium metabolism can lead to metastatic calcification, as is occasionally observed in patients with chronic renal failure. Furthermore, calcium may accumulate in necrotized cardiac myocytes, which is known as dystrophic calcification. The latter mechanism is believed to underlie myocardial calcification in the setting of myocardial infarc-Figure 1. ECG at day 1 of admission showing diffuse concave ST elevation with PR depression (arrow).

Reversible Myocardial Calcification Following Severe Leptospirosis Complicated With Rhabdomyolysis-Induced Acute Kidney Injury and Magnesium-Wasting Nephropathy

“…Myocardial calcification has been rarely reported in septic shock, despite the high incidence of the later [6][7][8][9][10][11]. Myocardial calcification has been also described in acute myocarditis [12,13].…”

A Curious Case of Acute Myocardial Calcifications

“…myocardial calcification, as used by van Kruijsdijk et al 2 This diagnosis should be considered in patients with established sepsis with new-onset diffuse myocardial calcifications, without arguments for metastatic myocardial calcification (as seen in patients with an abnormal serum level of calcium and phosphorus). A CT scan is the gold standard examination for the noninvasive detection of myocardial calcifications.…”

A case of extensive cardiac calcification

“…[14] Dystrophic calcification occurs in injured or necrotic myocardium with a normal serum calcium level. On the other hand, metastatic calcification can occur in previously healthy myocardium with malignant (parathyroid carcinoma, multiple myeloma, lymphoma, leukemia) or benign conditions (like chronic renal failure, hyperparathyroidism, and vitamin D excess) with calcium homeostasis abnormality.…”

“…[1] Though localized myocardial calcifications are common after myocardial infarction; extensive myocardial calcification is rarely reported. [1] Extensive myocardial calcification in the setting of severe acute pancreatitis (SAP) has not been described yet. We are sharing one such interesting case from our intensive care unit (ICU).…”