A 30-year-old man presented with nausea, vomiting, and chest and back pain, and was found to have elevated cardiac enzymes and EKG changes suggestive of ischemia. Coronary angiography showed normal arteries. Cardiac MRI revealed patchy enhancement most consistent with myocarditis.

1. 30-Year-Old Man With Chest Pain and Nausea
2015/10/19
Monday PBL
Kupsky DF, Tweet MS, Anavekar NS. 30-year-old man with chest pain and nausea. Mayo Clin Proc. 2014 Nov;89(11):1579-83.

7. A 30-year-old man with no notable medical history
presented to the emergency department with nausea, emesis,
and pain in his chest and between the shoulder blades.
既往歴：特になし
嘔気 嘔吐
=scapulas（肩甲骨）
救急外来

8. コリンズのVINDICATE鑑別診断法. 医学書院. 2014. p83より改変
解剖学的アプローチ × 病因的アプローチ（VINDICATE）
V I N D I C A T E
皮膚
筋肉
肋骨・軟骨
胸膜
肺
心膜
心筋
大動脈
食道
縦隔
胸椎
脊髄

9. Three days before presentation,
he noted the onset of the back pain
with associated vomiting and loose stools.
来院3日前
嘔吐 軟便

10. He reported feeling somewhat improved
over the course of the night into the next morning
but subsequently had development of diaphoresis
with return of the back pain.
ある程度は改善する
発汗

11. The recurrent episode was associated with chest pain
described as nonpositional, nonradiating substernal heaviness.
体位で変動しない 放散しない 胸骨下の

12. He had no cardiovascular risk factors.
心血管系

13. On physical examination,
he was afebrile,
with a pulse rate of 72 beats/min,
blood pressure of 113/77 mm Hg,
respiratory rate of 16 breaths/min,
and oxygen saturation of 100% while breathing room air.
無熱
脈拍数
血圧
呼吸数
酸素飽和度

14. Findings on physical examination,
including cardiopulmonary assessment,
were unremarkable.
心肺系

15. Basic laboratory studies yielded the following values
(reference ranges shown parenthetically):
hemoglobin, 12.7 g/dL (13.5-17.5 g/dL);
leukocytes, 9.2 × 109/L (3.5-10.5 × 109/L);
platelet count, 138 × 109/L (150-450 × 109/L);
erythrocyte sedimentation rate, 22 mm/h (0-22 mm/h);
and C-reactive protein, 43 mg/L (≤8 mg/L).
ヘモグロビン
白血球
血小板数
赤血球沈降速度（ESR）
C反応性タンパク（CRP）

16. His troponin T level increased
from 1.28 ng/mL (<0.01 ng/mL) at initial measurement
to 1.80 ng/mL at 3 hours
and 1.87 at 6 hours, a notable delta troponin.

17. Electrocardiography (ECG)

18. Initial electrocardiography (ECG)
yielded marked evidence of ischemia
with ST-segment elevations
in the inferior and anterolateral leads.
心電図
虚血
ST部分の上昇
下壁誘導 前壁・側壁誘導

19. A tombstone pattern was noted on the inferior leads
with near-linear ST segments.
下壁誘導
https://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/OahuCemetery-RevSamuelCDamon-tombstone.JPG/360px-OahuCemetery-RevSamuelCDamon-tombstone.JPG

20. Patterns on the anterior leads were less dramatic,
with concave ST-segment elevations.
凹型の

21. Guo XH, Yap YG, Chen LJ, et al. Correlation of coronary angiography with "tombstoning" electrocardiographic pattern in patients after acute myocardial infarction.
Clin Cardiol. 2000 May;23(5):347-52.
The criteria of tombstoning ST-segment elevation
a) absent R wave or an R wave duration <0.04 s with minimal amplitude
b) convex upward ST segment merging with the descending R
or the ascending QS/QR
c)the peak of the ST segment is higher than the R wave
d)the ST segment merges with the T wave

22. Balci B. Tombstoning ST-Elevation Myocardial Infarction. Curr Cardiol Rev. 2009 Nov;5(4):273-8
ST segment elevation meeting the criteria for tombstoning ECG.

23. ST segment elevation not meeting the criteria for tombstoning ECG.
Balci B. Tombstoning ST-Elevation Myocardial Infarction. Curr Cardiol Rev. 2009 Nov;5(4):273-8

24. Transthoracic echocardiography (TTE) indicated
a left ventricular ejection fraction (EF) of 53%
and inferolateral hypokinesis at the mid and base aspects of the heart,
and the entire apex was hypokinetic.
経胸壁 心臓超音波
左室駆出率
下側壁 運動低下 中間部 心基部
心尖部

25. The patient was stabilized, given morphine for the pain,
and urgently evaluated by the cardiology service
for further recommendations.
モルヒネ

26. Q: Which one of the following is the most important next step
in the management strategy ?
a. Initiation of intravenous lidocaine for the patient’s increased risk of
ventricular arrhythmias 心室性不整脈に備えて、リドカイン静注を始める
b. Nonsteroidal anti-inflammatory drugs(NSAIDs) and colchicine NSAIDsとコルヒチン
c. Admission to a telemetry-monitored unit with serial troponin measurements
and ECGs 遠隔モニターユニットに入室して、トロポニンと心電図を経時的に測定する
d. Dual antiplatelet therapy, symptom control, and catheterization laboratory
activation 抗血小板薬2剤、症状コントロール、カテ室準備
e. Initiation of statin therapy, β-blockade, and angiotensin-converting enzyme
(ACE) inhibition スタチン、βブロッカー、ACE阻害薬を開始する

27. Coronary angiography revealed normal coronary arteries.
The patient’s chest pain abated, and ECG documented
resolution of ST-segment elevations over time.
冠動脈造影

28. Q: Because the work-up thus far has yielded inconclusive results,
which one of the following would be the best next step
in establishing a diagnosis?
a. Endomyocardial biopsy 心内膜心筋生検
b. Cardiac magnetic resonance imaging (MRI) 心臓MRI
c. Transesophageal echocardiogram 経食道心臓超音波
d. Pericardial biopsy 心膜生検
e. Catheterization of the right side of the heart 右心カテーテル

29. The patient underwent MRI,
which revealed mild global hypokinesis, an EF of 49%,
and patchy delayed enhancement
involving mostly the epicardial regions at the apex.
遅延造影
心外膜 心尖部
壁運動低下

30. The distribution of enhancement was most suggestive of myocarditis.

31. Cardiovascular magnetic resonance criteria for myocarditis (Lake Louise Criteria) in the same patients:
regional myocardial edema (top left), hyperemia in images acquired early after contrast injection (top right),
and inflammatory necrosis in images acquired late (>10 minutes) after contrast injection (bottom).
Matthias G. Friedrich, and François Marcotte. Circ Cardiovasc Imaging. 2013;6:833-839

32. Q: Which one of the following viral organisms is
least commonly implicated in viral myocarditis?
a. Hepatitis C virus
b. Coxsackie B virus
c. Adenovirus
d. Parvovirus B19
e. Rotavirus

33. Q: Which one of the following would be the best treatment option
in this patient with the suspected diagnosis of myocarditis?
a. Antiviral therapy with ribavirin or interferon alfa
b. Immunosuppressive therapy including corticosteroids
and cyclosporinea
c. Conservative therapy with aspirin and NSAIDs
d. Intravenous immunoglobulins
e. Dual antiplatelet therapy with clopidogrel and aspirin for 6 months

34. 病原因子
エンテロウイルス、パルボウイルス、C型肝炎ウイルス、ヒトヘルペスウイルス6型など。
その他、HIV、CMV、Borrelia burgdorferi、Lyme病など。
非感染性（薬剤性、好酸球性、巨細胞性、サルコイドーシス、アミロイドーシスなど）
臨床症状
劇症型から急性、慢性のものまで重症度・経過が多彩。
胸痛、心不全、ショック、心外膜炎、不整脈、心臓突然死など。易疲労感のようなはっきりしない
症状のことも。
診断
心臓MRIが有用
T2強調画像とGd造影画像の組み合わせで、感度76%、特異度96%
虚血でも心筋炎に似た異常像がみられるが、虚血では心内膜側に病変があることから区別可能。
心筋生検は、巨細胞性心筋炎を強く疑うとき以外はリスクが高く、積極的には推奨されない。
治療
支持的療法が中心
ACE阻害薬、βブロッカー、利尿薬などの一般的な心不全加療
巨細胞性心筋炎では免疫抑制が有効
心筋炎 myocarditis

35. Take Home Message
致死的なものから考える。解剖学的にもれなく考える。
持続する胸痛は心筋梗塞だと思え
心筋炎も頭の片隅に入れといて