A 19 year old man developed acute chills, followed by fever and - one week later - severe lymphadenopathy and a sore throat. His 15y old sister had shared a glass of hzelnuz spread using the same spoon shortly before the young man developed his first symptoms. She developed the same symptoms about 3 weeks. A serology confirmed Ebstein-Barr Virus (EBV) and thus infectious mononucleosis in both of them. In addition, the brother developed severe hepatosplenomegaly, that persisted over 3 months.
BEcause of persisting fatigue and exertional dyspnea, a cardiac workup was performed in the young man. In the ECG, there was widespread ST elevation, consistent with pericarditis, yet more pronounced in the inferolateral wall. A subsequent cardiovascular MR (CMR) scan showed all three criteria of myocarditis: Myocardial hyperemia, edema and non-myocardial necrosis in a non-ischemic regional distribution. Furthermore, left-ventricular ejection fraction was borderline (54%) and LV mass was increased. Because of the myocardial involvement, the patient was advised to avoid severe physical stress for 4 weeks and was treated with Ibuprofen.
The girl's symptoms were similar, combined with bouts of depressive mood swings. A CMR scan showed widespread myocardial edema and pericardial effusion, while her systolic function was normal.
Only after 7 months, fatigue and exertional dyspnea began to decrease in both. A follow-up CMR scan showed persistent pericardial effusion in both, while systolic function was normal in both and edema had resolved. In the young man, LV mass had normalized.
These cases indicate that in young adults with a history of mononucleosis, chronic fatigue and exertional dyspnea may be associated with perimyocardial involvement and thus should be considered.
Because of its versatility and safety profile, CMR is a useful technique in young patients to verify or exclude pericardial and myocardial involvement in systemic viral disease.