35yo Male

Symptoms: Shortness of breath during physical exercise, lesser tolerance for physical activity, cough

Other afflictions: Asthma (diagnosed a couple of months ago), pneumonia with suspicion of eozinophil infiltration

Interview:
Cough
Fever
Patient denies all questions about infectious diseases  (including HIV, HCV, flu)
Doesn't do drugs
No contact with toxic substances
Family interview unnecessary

Physical examination
Heart: Tachycardia - 100 bpm, quiet tones with 3rd tone, systolic murmur,
Lungs: Crepitations in bases of both lungs, enlarged expiration ,
Stomach: regular,
Lower limbs: traces of oedemas in both ankles

First suspicions: heart failure, bilateral pneumonia.

Chest X-Ray: blending infiltrations in central and lower areas of both lungs, enlarged heart silhouette

Unconfirmed: Heart failure or bilateral pneumonia.

Laboratory tests:

Morphology: RBC - 4,6*10^6, WBC 27.3*10^3/L(range 4-10*10^3/L), absolute eosinophilia 15.1s\*10^3/L (0.1-0.7 x10^3/L), PLT

Markers of heart muscle necrosis:
Tp T 0,05 ug/ml (n<0,03), CPK MB 18 IU/L (n<25)
BNP - 536 pg/ml (norm <100 pg/mL)

Diagnosis is still uncertain, but tests suggest that heart failure is more probably than bilateral pneumonia.

Next step: ECG and UCG:

Extended diagnostics:

1. Coronarography - regular
   
2. MRI - features of cellular oedema
3. Endomyocardial biopsy - thickened endocardium, low cells count, fibrosis (pictured below)

Final diagnosis: Myocarditis eosinophillica

Treatment:

• Prednisone 1 mg/kg/day
• Enoxaparin 1 mg/kg/day
• ACE,
  
• LBA,
  
• Furosemide,
  
• Spironolactone
  

Thanks to Celina Wojciechowska MD for providing access to materials for this case.