Unusual instance of a condition featuring numerous autoimmune disorders, with myocarditis being a key component, as detailed in a case study report.
A 46-year-old female patient with known autoimmune disorders, rheumatoid arthritis (RA) and secondary Sjögren's syndrome (GSJ), presented with a case of myocarditis, a condition often associated with autoimmune diseases.
The patient's biological data revealed a markedly elevated troponin level of 1090 ng/ml, a common marker for myocardial damage. Myocarditis is most frequently linked with autoimmune diseases such as RA and Sjögren's, among others, in the context of multiple autoimmune syndrome (MAS).
In the case of RA, the disease is connected to myocarditis through systemic inflammation and autoimmune responses that may target cardiac tissue. Sjögren's is frequently associated with systemic autoimmune activity, including antibodies such as anti-Ro52, which have been implicated in cardiac inflammation.
Other autoimmune disorders commonly associated with myocarditis, especially in the MAS context, include systemic lupus erythematosus, inflammatory myositis, and autoimmune overlap syndromes. These diseases share immunopathogenic pathways that can trigger myocarditis through autoantibody production and inflammatory cytokine milieu.
The patient was admitted to the cardiac intensive care unit and was treated with 20 mg hydrocortisone daily and adjuvant therapy including folic acid and vitamin D. Her medication compliance was poor, and she was also administered 20 mg methotrexate weekly. During the hospitalization, follow-up echocardiography revealed a left ventricule of normal size and a significant improvement in global and segmental systolic function.
Cardiac MRI is considered the test of choice for monitoring cardiotoxicity in patients undergoing long-term treatment with disease-modifying antirheumatic drugs (DMARDs). In patients with myocarditis, higher T1, T2, and extracellular volume fraction (ECV) values are commonly observed compared to controls, along with a modest prevalence of late gadolinium enhancement (LGE) at 18%.
The occurrence of myocarditis during the course of an autoimmune disease creates a complex clinical scenario, necessitating further research to better guide management strategies. The guideline-based therapy for patients with acute myocarditis includes supportive therapy for left ventricular dysfunction, such as beta-blockers and angiotensin-converting enzyme (ACE) inhibitors.
It is important to note that myocarditis is not exclusive to patients with autoimmune diseases, as autoantibodies targeting heart muscle components are also detected in individuals with other cardiovascular diseases. However, the co-occurrence of at least 3 autoimmune diseases in a single patient is classified as MAS.
The patient's case is noteworthy due to the uncommon occurrence of myocarditis in RA and Sjögren's syndromes. Myocardial biopsy can be useful for distinguishing between autoimmune myocarditis and viral myocarditis, but it is less informative when inflammatory infiltrates are present without identifiable pathogens. In such cases, the use of leucovorin (or folinic acid) at a dose of 100 mg/m2 every 6 hours for 24 hours is recommended to mitigate potential toxicity. The patient was discharged after a 3-day stay.
- Ultrasonography revealed the patient's heart was functioning normally following treatment.
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