ABC | Volume 112, Nº4, April 2019

Anatomopathological Correlation Pereira et al Arrhythmia and heart failure Arq Bras Cardiol. 2019; 112(4):466-472 vascular resistance was 1.8 Woods and the systemic vascular resistance was 887 dynes/sec/cm -5 . The transplantation was performed in March 2016 using the bicaval orthotopic heart transplantation technique, without complications; the patient received prophylactic antimicrobial treatment with vancomycin and cefepime. After the transplantation, the immunosuppressant drugs prednisone, cyclosporine and mycophenolate were introduced. Endomyocardial biopsies performed on March 21 and 31 showed grade I rejection and cytomegalovirus tests were negative. The echocardiogram performed at hospital discharge on 03/28/2016 showed left atrium of 42 mm, septum and posterior wall of 11 mm, left ventricle of 50x31 with ejection fraction of 68%; normal right ventricle and pulmonary artery pressure of 35 mmHg. The medication prescribed at the hospital discharge consisted of cyclosporin 100mg + 75mg daily, prednisone 40mg 1x / day, mycophenolate sodium 720mg every 12h. At the outpatient clinic consultations he remained asymptomatic (April 2017). He currently takes Tacrolimus 4 mg 2x/day; prednisone 5 mg; mycophenolate 720 mg 2x/day; diltiazem 30 mg 3x/day; simvastatin 10 mg 1x/day; vitamin D 900 mg/day; and omeprazole 20mg 1 x/day. Clinical aspects The patient developed arrhythmia at 26 years of age. At age 33, in 2013, he developed heart failure, which rapidly progressed to functional class IV, with consecutive hospitalizations due to acute decompensation. In 2015, after the last hospitalization, he was placed on the priority list for heart transplantation due to clinical treatment refractoriness. In March 2016 he underwent the procedure and remained asymptomatic, being followed through outpatient clinic consultations since April 2017. This is a heart failure case with important aspects that must be investigated: etiology and factors for decompensation. It is suggested that the probable cause of the index event is myocarditis or idiopathic dilated cardiomyopathy in a 30-year-old man. The American Heart Association classifies primary cardiomyopathies (predominant heart involvement) into three groups: genetic (hypertrophic cardiomyopathy, right ventricular arrhythmogenic cardiomyopathy, noncompacted left ventricle, glycogen accumulation disease, mitochondrial myopathies and channelopathies); mixed, predominantly non‑genetic (dilated cardiomyopathy, restrictive); and acquired (inflammatory (myocarditis), caused by stress (Takotsubo), peripartum, induced by tachycardia, and of the infant, child of an insulin-dependent mother. 1 The origin of inflammatory heart diseases can be: autoimmune (connective tissue diseases, sarcoidosis, eosinophilic diseases); inflammatory diseases (hypersensitivity myocarditis, endomyocardial fibrosis, hypereosinophilic syndrome); toxic (antineoplastic chemotherapeutic drugs); and infectious (protozoa, fungi, bacteria, viruses and parasites). 2 Among the infiltrative diseases, which usually occur simultaneously with restrictive syndrome, are: amyloidosis, sarcoidosis and deposition diseases (Fabry, and others). 3 Amyloidosis could be the etiology of the patient's heart disease, since it is a progressive disease, affects adults from the age of 30 years and its frequent form of extracardiac involvement is kidney disease. In this context, the patient was close to 30 years old and his urinalysis showed the presence of proteinuria. Additionally, the ECG in amyloidosis usually shows atrioventricular block, supraventricular and ventricular arrhythmias, as the patient showed at the beginning of the clinical picture. However, the typical findings at the magnetic resonance and echocardiogram show an enlargement of the septum and posterior wall, which were absent in the present case. In sarcoidosis, there is a more frequent involvement of individuals between 25 and 60 years, and it is positively associated with lung and lymph node involvement and frequent extracardiac alterations, which were absent in the patient. Fabry disease, on the other hand, manifests in childhood or adolescence, and shows important dermatological findings, which rule out the possibility of this diagnosis. Regarding the complementary exams, amyloidosis and Fabry's disease show findings that are similar to sarcoidosis on the ECG, magnetic resonance imaging and echocardiogram. 4,5 However, there are no reports of autoimmune tests, extracardiac investigations, much less the performance of endomyocardial biopsy in the current patient with rapidly progressive heart failure, without a definitive cause, not responsive to clinical treatment and with hemodynamic deterioration. 5 Recreational drug poisoning, such as alcohol, amphetamines, cocaine and the use of anabolic drugs could be possible causes for myocarditis, considering that the patient is young and a potential user of these drugs. However, the current case does not show a history of drug addiction or drug abuse. Moreover, drug poisoning is expressed by chamber dilatation and not by myocardial thickening. In South America and Brazil, the Chagasic etiology is a frequent form of myocarditis. However, the patient did not have alterations in the ECG and echocardiogram suggestive of this disease. There was no evidence of right bundle-branch block, anterosuperior divisional block, apical aneurysm, right heart failure manifestations, and the patient did not show positive epidemiology for Chagas disease. 5-7 Viruses are also frequent infectious myocarditis agents, with the most common agents being adenovirus, enterovirus, parvovirus, herpes simplex, hepatitis C virus, cytomegalovirus and Epstein-Barr virus. However, magnetic resonance imaging shows thickening of the septum and posterior wall, which indicates other causes of myocarditis, since the infectious one is associated with dilated cardiomyopathy. 8 However, there was not a complete investigation to elucidate a possible infectious cause, either by serology or by endomyocardial biopsy of the right ventricle. The patient is young, viral contaminations are common, he may have circulated in areas of greater risk for Chagas disease contamination and be sexually active, increasing the chances of being infected with HIV and different types of hepatitis. 8 467