Myocarditis

Report:

Sinus rhythm 88/min

Prolonged QT interval

QTc 0.50”

Diffuse T wave inversion

Comment:

T wave changes, by themselves, are virtually never diagnostic of anything. In this setting, they are consistent with myocarditis or ischæmia. They are deeper than usual for myocarditis and less than usually symmetrical for ischæmia. The cardiac enzymes remained normal and an echocardiogram showed mild LVH and nothing else. Finally, as happened in the similar Case 194, coronary angiography was performed and was normal.

The diagnosis entered into the patient’s record was pericarditis, but the only evidence for this was the pleuritic chest pain. She may well have had pericarditis as well, but the ECG and the echocardiogram did not support the diagnosis; sometimes they are negative in pericarditis proven at autopsy. The pain, on the other hand, being pleuritic, may well have been actually pleural! Myocarditis is more likely electrocardiographically, although the pattern of deep T wave inversion remains somewhat atypical. It is possible that underlying LVH (also present in Case 194) exaggerates the T wave inversion in myocarditis.

Her baseline ECG, taken two months previously, is shown below (Fig 118a).