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Acute Nonrheumatic Streptococcal Myocarditis: STEMI Mimic in Young Adults

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Abstract

Background

Mimicking ST-segment elevation myocardial infarction upon presentation, acute nonrheumatic streptococcal myocarditis is a treatable etiology of myocarditis which has only been infrequently reported.

Methods

Patients were identified through a retrospective query of electronic medical records over a 17-year period (January 1994 to December 2010). We describe a case series of acute nonrheumatic streptococcal myocarditis complicating pharyngitis in young adults.

Results

Nine patients were identified; 89% were male, patients had an average age of 28.6 years, and 56% and 22% had confirmed group A and group G streptococcus, respectively. Latency from pharyngitis to chest pain averaged 3.1 ± 1.1 days. No patients met the revised Jones criteria for acute rheumatic fever. All 9 patients (100%) presented with ST-segment elevations on electrocardiography and elevated cardiac biomarkers. Average peak creatine kinase was 934 U/L (normal < 400 U/L), creatine kinase-MB was 82 ng/mL (normal < 6.9 ng/mL), and troponin T was 2.30 ng/mL (normal < 0.03 ng/mL). Six patients underwent coronary angiography, which revealed no obstructive culprit lesions. Cardiac magnetic resonance imaging confirmed myocarditis in 3 patients and was used to document resolution in follow-up for 2 patients. All patients had a complete clinical recovery.

Conclusions

Acute nonrheumatic streptococcal myocarditis is an under-recognized and treatable cause of ST-segment elevation and chest pain in young adults with a history of recent pharyngitis. Etiopathology extends beyond Lancefield group A streptococcus and includes group G streptococcal infection. Cardiac magnetic resonance may be useful in confirming the diagnosis and documenting the resolution.

Section snippets

Materials and Methods

We retrospectively reviewed all cases of acute nonrheumatic streptococcal myocarditis over a 17-year period (January 1994 to December 2010). Patients were identified using a hospital-wide database containing admission, discharge, and associated diagnoses. Search terms included any combination of tonsillitis, acute tonsillitis, infective tonsillitis, peritonsillitis, pharyngotonsillitis, suppurative tonsillitis, streptococcal tonsillitis, streptococcal sore throat, group A streptococcal

Results

Nine patients with acute nonrheumatic streptococcal myocarditis were identified; 89% were male, and the average age was 28.6 years. No patients had a history of cardiovascular disease or rheumatic fever. Key clinical characteristics are presented in Table 1 with a summary in Table 2. The majority of patients (78%) had streptococcal pharyngitis confirmed via microbiologic testing at Massachusetts General Hospital; microbiologic assay results were not available for review in 2 patients who were

Discussion

We present the largest single-center case series of acute nonrheumatic streptococcal myocarditis in the United States. Acute nonrheumatic streptococcal myocarditis mimics acute coronary syndrome on presentation and should be considered in the differential of young persons presenting with chest pain. Hallmark features include a history of pharyngitis, ST-segment elevations on electrocardiogram, and an average latency period of 3 days after throat symptoms. Previous reports have suggested the

Conclusions

Acute nonrheumatic streptococcal myocarditis should be considered in the differential diagnosis of young patients presenting with ST-segment elevations, chest pain, and a history of sore throat. Rapid antigen testing is sufficient for diagnosing streptococcal infection, and absence of anti-streptolysin O and anti-DNAse B elevation confirms acuity. CMR imaging may be used to assess disease severity and document resolution. Of note, unlike many forms of viral myocarditis, acute nonrheumatic

References (12)

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Funding: None.

Conflict of Interest: None.

Authorship: All authors had access to the data and played a role in writing this manuscript.

Drs Upadhyay and Gainor contributed equally to the investigation.

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