Subacute Rhinovirus Myocarditis Complicating Nonischemic Alcohol-Induced Dilated Cardiomyopathy: Unusual Mixed Etiologies of Biventricular Heart Failure

ABSTRACT

Background Dilated cardiomyopathy (DCM) is caused by many conditions, including ischemia, genetics, infection, chemotherapy, or idiopathic. Clinical suspicion is needed to identify reversible etiologies. Case A middle-aged truck-driver presents with exertional dyspnea, cough, lower extremity edema, and low-grade fever for 2 weeks. He had 20-pack-year smoking history and 3-4 alcoholic drinks weekly. Chest x-ray showed pulmonary congestion. BNP was elevated. ECHO showed severely dilated ventricles with LVEF < 10% and no wall abnormalities. Decision-making Perfusion stress test showed no inducible ischemia. Coronary angiogram showed no epicardial disease. Cardiac MRI (CMR) showed severely dilated biventricular failure, pericardial thickening, circumferential pericardial effusion, epicardial involvement suggestive of subacute myopericardial inflammation and scarring with delayed gadolinium-enhancement and RVEF < 5%. Liver ultrasound showed no cirrhosis. Viral PCR was positive for rhinovirus, negative COVID-19. He was treated medically requiring inotropes then transferred to heart failure center for assist device evaluation. Conclusion Our patient reported moderate alcohol use, which alone would not explain the myopericardial changes seen on CMR. Given the findings, his DCM was attributed to alcohol complicated by possible subacute rhinovirus myocarditis. Our association is further supported by recent respiratory viral prodrome along with exclusion of other etiologies. [Formula presented]Copyright © 2023 American College of Cardiology Foundation