Meghan Prin, MD, MS
Assistant Professor
University of Colorado, United States
Disclosure information not submitted.
Samuel Gilliland, MD
Assistant Professor, Department of Anesthesiology and Critical Care
University of Colorado, Anschutz Medical Campus, United States
Disclosure information not submitted.
Caitlin Blaine, PA-C, MSHS
Physician Assistant
University of Colorado Anschutz Medical Campus
Aurora, CO
Disclosure information not submitted.
Title: ECMO in a patient with latent DRESS Syndrome-associated Fulminant Myocarditis
Case Report Body:
Introduction: Myocarditis is a rare and morbid association with Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Extracorporeal membrane oxygenation (ECMO) was used successfully for circulatory support in a woman with recurrent DRESS and fulminant myocarditis.
Description: A 30 year old female with seizure disorder developed DRESS syndrome after treatment with lamotrigine. The offending agent was discontinued and she required chronic immunosuppression. Nine months following her initial illness she presented with chest pain, mild troponin elevation and an unremarkable echocardiogram (ECHO). She was discharged after treatment with steroids and colchicine but returned one month later with recurrent chest pain, troponin >20,000mg/dL, dyspnea, leukocytosis and eosinophilia. Coronary angiography was normal but an ECHO revealed significantly reduced ejection fraction. She then suffered VT arrest requiring cardioversion, intubation and emergent peripheral venoarterial ECMO cannulation, after which she was transferred to our institution. She arrived in pulseless VT with a circumferential pericardial effusion on TTE. After treatment with amiodarone and lidocaine infusions she converted to sinus rhythm and regained pulsatility, augmented by a dobutamine infusion. High dose steroids were started empirically. Endomyocardial biopsy revealed eosinophilic myocarditis. She was decannulated after three days of mechanical support with an ejection fraction of 45% and eventually discharged on mycophenolate, a steroid taper and an interleukin-5 inhibitor. A follow up ECHO one month later showed fully recovered biventricular function, no wall motion abnormalities, and no pericardial effusion.
Discussion: The incidence of myocarditis in DRESS is unknown but likely underestimated and can present on spectrum from mild troponinemia and chest pain to fulminant myocarditis, arrhythmia, and cardiac arrest. Death often results from malignant arrhythmias as were seen in our patient. Our case highlights the benefit of ECMO support concurrently with optimization of malignant arrhythmias and immunosuppression which facilitated a quick cardiac recovery and early decannulation. As ECMO becomes more readily available what was once a life-threatening condition with a high incidence of mortality may become more routinely survivable.