A CASE OF WEST NILE VIRUS MYOCARDITIS PRESENTING AS NON-ST ELEVATION MYOCARDIAL INFARCTION

Purpose: This case study will present an atypical presentation of West Nile Virus (WNV) myocarditis in a Hispanic male who presented with palpitations, syncope and chest pain consistent with NSTEMI. Typically, WNV infection is asymptomatic; those who are symptomatic present most commonly with WNV and neuroinvasive disease. Myocarditis is an atypical presentation of West Nile Virus infection. We will illustrate the clinical presentation of WNV myocarditis that initially presented as NSTEMI. Methods: The patient's hospital records, including labs, echocardiography findings and cardiac catherization findings, were reviewed. Results: A 38 year old Hispanic male with a previous history of hypertension, hemorrhagic stroke, hyperlipidemia, sleep apnea, metabolic syndrome and gout presented after falling in his home with a chief complaint of elbow, head, neck and chest pain. The patient reported syncope, palpitations, chest pain but no symptoms associated with seizures. Labs showed elevated troponin of 1.385 and a WBC of 21.4. ECG revealed sinus tachycardia, left axis deviation, left atrial enlargement, left anterior fascicular block and nonspecific ST and T wave abnormalities. The patient was admitted on IV antibiotics and serial troponins were monitored. During the course of the admission, cardiac enzymes progressively trended down. Left heart catherization showed minimum irregularities of the left anterior descending less than 20% without evidence of any obstructive coronary artery disease lesions in any of the coronary arteries. Echocardiogram revealed new heart failure with LV ejection fraction of 35-40% due to global cardiomyopathy. Prior to discharge, the patient was tested for West Nile Virus antibodies and viral antigens. He was sent home on maximum medical therapy for coronary artery disease and CHF. West Nile Virus serology was obtained several days after discharge and revealed that the patient was positive for West Nile Virus infection. Conclusions: This case highlights the need for further investigation of cases presenting with increased troponins and suspicion for NSTEMI. Viral myocarditis should be suspected in symptomatic patients who present during mosquito seasons with new onset and persisting headache with chest pain, increased troponins, significant ECG changes, or new onset CHF. Specifically, West Nile Virus has now been implicated in cases with significant cardiac involvement and should be included in any differential diagnosis concerning the etiology of cardiac events.