Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 4, Number 12, December 2013, pages 775-779

Infiltrative Disease in Non-Ischemic Cardiomyopathy: Giant Cell Myocarditis Leading to Fulminant Myocarditis


Figure 1.
Figure 1. Heart, apical core biopsy. Section of myocardial biopsy shows extensive myocardial necrosis and chronic inflammation with lymphocytes, eosinophils, and many giant cells. No granulomas are identified. Giant Cell Myocarditis 4 × H & E Stain
Figure 2.
Figure 2. Giant Cell Myocarditis 10 × CD4. Giant Cell Myocarditis 10 × CD8. Heart, apical core biopsy. CD4 and CD8 immunostains show a mixture of CD4 and CD8 positive T cells (CD4 > CD8). Histologic findings are consistent with diagnosis of giant cell myocarditis. Absence of granulomas with extensive necrosis and presence of eosinophils argue against the possibility of sarcoidosis. GMS, AFB stains are negative for fungi and acid fast bacilli.


Table 1. Classification of Different Subtypes of Myocarditis
Parameters ConsideredFulminantAcuteChronic activeChronic persistent
DCM, dilated cardiomyopathy; LV, left ventricle; Permission obtained from Elsevier Ltd@ Lieberman EB et al (1991) J Am Coll Cardiol 18: 1617 – 1626.
Onset of cardiac symptomsAbruptInsidiousInsidiousInsidious
Initial presentationCardiogenic shockHeart failure with LV dysfunctionHeart failure with LV dysfunctionAsymptomatic and no LV dysfunction
Initial endomyocardial biopsy findingsMultiple foci of active myocarditisActive or borderline myocarditisActive or borderline myocarditisActive or borderline myocarditis
Clinical courseComplete recovery or deathIncomplete recovery or chronic, stable DCMProgressive end-stage DMMild symptoms with stable LV function
Histologic courseComplete resolutionComplete resolutionOngoing or resolving myocarditis; fibrosis and giant cellsPersistent inflammation with foci of myocyte necrosis
Response to immunosuppressive therapyNo benefitVariableInitial response followed by relapsesNo benefit


Table 2. Differential for Fulminant Myocarditis
Differential diagnosisAssociated conditionsKey clinical featuresKey histologic findingsTreatment
Sachin G, Markham DW, Drazner MH, Mammen PP. Fulminant Myocarditis. Nat Clin Prac. 2008; 5: 693-706.
Giant cell myocarditisAutoimmune disorders Thymoma Drug hypersensitivity to minocycline, cephalosporins, phenytoin, primidoneMalignant ventricular tachycardia Heart blockMultinucleated giant cellsHigh-dose steroids and cyclosporine or azathioprine Cardiac transplantation
Necrotizing eosinophilic myocarditisAllergic diathesis Churg-Strauss syndrome Idiopathic hypereosinophilic syndrome Endomyocardial fibrosisFlu-like symptoms Peripheral blood eosinophiliaDiffuse infiltration with eosinophils and extensive myocyte necrosisHigh-dose steroids
SarcoidosisAutoimmune disordersArrhythmias Hilar adenopathyNoncaseating granulomasHigh-dose steroids Cardiac transplantation
Peripartum cardiomyopathyNoneTime of onset related to pregnancyMild-to-moderate lymphocytic infiltration with myocyte necrosisSpontaneous recovery High-dose steroids and azathioprine LVAD Cardiac Transplantation Bromocriptine
Acute myocardial infarctionHypertension Diabetes mellitus Peripheral vascular disease DyslipidemiaElectrocardiographic evidence of ischemiaThrombus in coronary arteries with myocyte necrosisCoronary angioplasty IABP LVAD