2013) 1138.e3e1138.e5 www.onlinecjc.caCanadian Journal of Cardiology 29 (Case Report

Erysipelas and Acute Myocarditis: An Unusual CombinationFernando Domnguez, MD,a Marta Cobo-Marcos, MD,a Gonzalo Guzzo, MD,a

Miguel A. Cavero, MD,a Jess G. Mirelis, MD,a,b Luis Alonso-Pulpon, MD, PhD,a and

Pablo Garcia-Pavia, MD, PhDaaDepartment of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain

bCentro Nacional de Investigaciones Cardiovasculares, Madrid, SpainABSTRACTMyocarditis is a rare disease with variable clinical presentation anddiverse electrocardiographic and echocardiographic features. Viralinfection is the most common cause, but myocarditis can also becaused by bacterial infection. The most frequently involved bacterialagent is group A Streptococcus, which is also an etiologic agent oferysipelas. We present the case of a man aged 46 years with left-legerysipelas who developed myocarditis. Cardiac magnetic resonanceplayed an essential role in diagnosis. This case is, to our knowledge,the first description of an association between erysipelas andmyocarditis.Received for publication October 28, 2012. Accepted December 22, 2012.

Corresponding author: Dr Pablo Garcia-Pavia, Department of Cardi-ology, Hospital Universitario Puerta de Hierro, Manuel de Falla, 2, 28222Madrid, Spain.

E-mail: pablogpavia@yahoo.esSee page 1138.e4 for disclosure information.

0828-282X/$ - see front matter 2013 Canadian Cardiovascular Society. Publishehttp://dx.doi.org/10.1016/j.cjca.2012.12.021RESUMELa myocardite est une maladie rare ayant un tableau cliniquevariable, et diverses caracteristiques electrocardiographiques etechocardiographiques. Linfection virale est la cause la plus frequente,mais la myocardite peut egalement tre causee par linfectionbacterienne. Lagent bacteriologique le plus frequemment en causeest le streptocoque du groupe A, qui est egalement un agentetiologique de lerysiple. Nous presentons le cas dun homme ge de46 ans ayant un erysiple la jambe gauche chez qui une myocarditeest survenue. La resonance magnetique cardiaque a joue un rlediagnostique primordial. notre connaissance, ce cas montre pour lapremire fois un lien entre lerysiple et la myocardite.Case PresentationA man aged 46 years with a history of tobacco abuse and

hypertension presented to emergency with 24-hour lower leftlimb pain and circumscribed erythema. The lesion did notdisappear after pressure, there was no edema, and the patientdenied previous trauma or insect bite (Fig. 1). However, thepatient did have a painless hyperkeratotic lesion with a centralcrack on his left sole. The patient denied chest pain, dyspnea,palpitations, presyncope, syncope, and recent viral illness andwas not taking medication. Physical examination was normalbesides the skin lesion.

While in the emergency department, the patient sufferedvasovagal syncope with a pulse of 60 beats per minute andblood pressure 74/45 mm Hg, preceded by diaphoresis,dizziness, and blurred vision. After a few seconds, he recoveredconsciousness and reported no chest pain, palpitations, orother symptoms. An immediately postsyncope electrocardio-gram (ECG) showed junctional rhythm at 60 beats perminute, which persisted for 10 minutes. Thirty minutes later,the ECG showed ST elevation in leads I and II and from V2to V6.

Cardiac enzymes were elevated (Troponin I, 33 mg/L,and creatine kinase, 514 U/L; normal values: < 0.06 mg/Land < 195 U/L, respectively). An urgent coronary angiogramshowed normal epicardial arteries, and a computed tomog-raphy scan excluded pulmonary thromboembolism.A transthoracic echocardiogram demonstrated preserved leftventricular function without valvular dysfunction or peri-cardial effusion.

The patient was admitted to the cardiology ward, andcardiac magnetic resonance imagery (CMRI) establisheda diagnosis of acute myocarditis, with preserved biventricularfunction with inferolateral and anterolateral subepicardialenhancement in short T1 inversion recovery (STIR) sequences(Fig. 2). Gadolinium CMRI revealed delayed subepicardialcontrast enhancement that matched the STIR sequences,indicating a potentially reversible lesion. No pericardial effu-sion or thickening was present.

Skin lesion and blood cultures were negative for bacteriaand fungi, and blood tests were negative for HIV and hepatitisC. Immunologic studies (antinuclear antibody, antineutrophilcytoplasmic antibody, rheumatoid factor) and antistreptolysinO (ASO) test were normal. A skin biopsy showed classicalfindings of erysipelas.d by Elsevier Inc. All rights reserved.

mailto:pablogpavia@yahoo.eshttp://dx.doi.org/10.1016/j.cjca.2012.12.021http://dx.doi.org/10.1016/j.cjca.2012.12.021http://dx.doi.org/10.1016/j.cjca.2012.12.021

Figure 1. Erysipelas in the lower left limb.

1138.e4 Canadian Journal of CardiologyVolume 29 2013No further complications were observed, and the patientwas discharged after 6 days. The skin lesion improved aftertreatment with amoxicillineclavulanic acid. At outpatientvisits 2 and 6 months after discharge, the patient remainedasymptomatic. CMRI 6 months after the initial visit wasnormal.DiscussionThe clinical presentation of myocarditis is highly variable,

with divergent ECG and echocardiographic findings. CMRIhas become an essential test for accurate diagnosis1,2 and ishighly valuable for predicting clinical outcome.3

Erysipelas is mainly caused by infection with group Ab-hemolytic Streptococcus. Diagnosis is based on the typicalclinical presentation. ASO is elevated in only 40% of patients,and blood cultures are positive in only 5%. SystemicFigure 2. Cardiac magnetic resonance imaging. (A) Short-axis view of the lefnormal myocardium) is seen in the anterolateral subepicardial area (whiteGadolinium deposits are found at the same location (black arrow).involvement is usually mild. Although microbiological testsare usually negative, a common causative agent is group Ab-hemolytic Streptococcus, which has also been linked to thedevelopment of myocarditis when infection affects the upperrespiratory tract.4

Streptococcal infection can damage the heart througha variety of mechanisms. First, myocarditis can occur in thesetting of rheumatic fever. However, our patient did notshow any of the other Jones criteria, and the typical latencybetween streptococcal infection and carditis was absent.Moreover, the lack of streptococcal antibodies supportsa noneimmune-mediated process. Myocarditis can alsooccur with invasive streptococcal infection or toxic-shocksyndrome, typically fulminant, with a rapid onset andsevere skin manifestations, which were not present in thiscase. Toxin-mediated myocarditis seems to be the mostpopular explanation for previously described cases ofmyocarditis associated with streptococcal pharyngitis4,5 andhas been related histopathologically to nonspecific myocar-ditis in the absence of direct streptococcal bacterial invasion.Although we did not perform endomyocardial biopsy, toxin-induced myocarditis is the most probable explanation of ourcase, in view of the positive clinical outcome. This case is, toour knowledge, the first description of erysipelas complicatedby myocarditis.Funding SourcesThis work was partially supported by the Instituto de Salud

Carlos III [grant PI11/0699] and the Spanish Ministry ofHealth [Red Cooperativa de Insuficiencia Cardiaca (RED-INSCOR) RD06/03/0018].DisclosuresThe authors have no conflicts of interest to disclose.t ventricle in T2-weighted sequence. Increased signal (> 2 SD from thearrow). (B) Short-axis view with the delayed enhancement technique.

Domnguez et al. 1138.e5Erysipelas and Acute MyocarditisReferences

1. Garcia-Pavia P, Aguiar-Souto P, Silva-Melchor L, et al. Cardiac magneticresonance imaging in the diagnosis of myocarditis mimicking myocardialinfarction. Int J Cardiol 2006;112:e27-9.

2. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascularmagnetic resonance in myocarditis: a JACC white paper. J Am CollCardiol 2009;53:1475-87.3. Grn S, Schumm J, Greulich S, et al. Long-term follow-up of biopsy-proven viral myocarditis predictors of mortality and incomplete recovery.J Am Coll Cardiol 2012;59:1604-15.

4. Chaudhuri A, Woods ML, Dooris M. Non-rheumatic streptococcal myo-carditisdwarm hands, warm heart. J MedMicrobiol 2013;62(pt 1):169-72.

5. Gill MV, Klein NC, Cunha BA. Nonrheumatic poststreptococcalmyocarditis. Heart Lung 1995;24:425-6.

Erysipelas and Acute Myocarditis: An Unusual CombinationCase PresentationDiscussionFunding SourcesDisclosuresReferences