一例复杂心肌炎病例精彩解析

病史

患者女，37岁，中学教师，因“心慌、胸闷不适1天”入院。1天前晨起后出现心慌、胸闷，休息后稍有好转，未予重视。入院当天傍晚散步时自觉胸闷加重，感胸骨后闷痛，不能缓解，遂至我院急诊就诊，急查心电图（2016-07-24）：窦性心律，I、AVL、V1异常Q波，肢体导联低电压；D-二聚体：0.92mg/L；hs-Tn高敏肌钙蛋白T：966.4ng/L。

否认感冒病史

既往史、家族史无特殊

心肌标志物(2016-07-24)

血常规

ECG(2016-07-25)

CAG(2016-07-25)

UCG(2016-07-25)

尿常规

实验室检查

生化

实验室检查

Holter(2016-07-27)

治疗

辅酶Q10 10mg TID

倍他乐克 25mg BID

磷酸肌酸 2g IVP QD

患者胸痛胸闷缓解

骨髓细胞学检查(2016-07-27)

骨髓病理(2016-07-27)

心肌标志物(2016-07-28)

心肌活检(2016-08-01)

ECG(2016-08-01)

心肌活检（2016-08-01）

心肌标志物

2016-08-03

2016-08-09

UCG(2016-08-05)

ECG(2016-08-20)

UCG(2016-09-12)

相关知识：

Definition

Myocarditis is identified as an inflammatory disease of the heart muscle cells and is pathologically identified by conventional histology and immunohistochemical techniques as an infiltration of mononuclear cells to the myocardium

Immunohistochemical: exhibit ≥14 lymphocytes/mm2 including ≤4 monocytes/mm2 with the presence of CD3-positive T lymphocytes ≥7 cells/mm2

diagnosis

Biomarkers for myocarditis remain a poorly developed method of diagnosis, with relatively low prognostic value

Despite the low sensitivity of electrocardiograms, it is widely used as an initial screening tool

Ukena et al investigated the prognostic value of electrocardiography in patients suspected to have myocarditis and found that a prolonged QRS duration is a significant independent predictor for cardiac death or heart transplantation[1]

1.Prognostic electrocardiographic parameters in patients with suspected myocarditis.Eur J Heart Fail. 2011.

Endomyocardial Biopsy

EMB positivity in acute myocarditis patients is defined as lymphocytic infiltration in association with myocyte necrosis/death (Dallas Criteria)

ESC recommends the use of EMB as early as possible for histology, immunohistochemistry, and viral PCR analysis

ACC/AHA recommends EMB based on 3 classes of comprehensive clinical presentations, risks, and measurements using noninvasive techniques

EMB for detection of myocarditis is rather low, immunohistochemistry, miRNA profiling, nested polymerase chain reaction, and in situ hybridization has improved accuracy of diagnosis and prognostic value of EMB samples significantly