• Stanko Biocić, Zeljko Durasević, Boris Starcević, and Mario Udovicić.
• Department of Cardiovascular Diseases, University Department of Medicine, Dubrava University Hospital, Zagreb, Croatia.
• Acta Med Croatica. 2009 Oct 1;63(4):325-7.

AbstractMore than 20 viruses have been reported to cause myopericarditis, a rare but potentially dangerous complication. To our best knowledge only a few dozen cases of myopericarditis caused by varicella zoster virus have been reported, most frequently in children, seldom in immunocompetent adults. We report on a case of a myopericarditis caused by varicella zoster virus in a previously healthy young man, with a typical development and a fast and complete recovery. A 27-years-old male was admitted to our hospital with chest pain and signs of acute cardiac injury. He had no medical history of serious previous illnesses. Four weeks earlier, the patient was in contact with a child having chickenpox. Two days prior to admission patient became suddenly febrile up to 40 degrees C along with dry cough, and the following day intense chest pain set in. At the admission we found in the patient diffuse vesiculous exanthema on the whole body and capillitium. Heart beat was rhythmical with no audible murmurs or pericardial friction rub, 100 beats per minute, blood pressure RR 130/90 mm Hg, body temperature 37.4 degrees C, and ST segment elevation in lateral leads along with elevated cardiac markers were found. All parameters of complete blood count were within normal range. Chest X-ray showed somewhat enlarged heart with incipient signs of cardiac decompensation. Echocardiogram was normal, apart from a mild dyskinesis of the apical third of intraventricular septum, with ejection fraction slightly reduced to 50% and no valvular defect. Clinical diagnosis of acute infection with varicella zoster virus was confirmed serologically by a positive ELISA test. Patient received conservative therapy (isosorbide mononitrate, low molecular weight heparin, acetylsalicylic acid and bisoprolol), while he remained hemodinamically, and apart from one non sustained ventricular tachycardia immediately after admission, also rhythmically stable. During his stay in hospital we observed the typical evolution and regression of rash while the levels of cardiac markers normalised, with patient becoming afebrile the third day. Before dismission a control echocardiograph showed improvement of contractile function, ejection fraction improved to 65%, but also signs of mild pericarditis were recorded. Since the patient had no discomfort and was in a very good shape, he was dismissed from hospital with ibuprofen 400 mg twice a day as therapy. Two months later, the patient was readmitted for control. In the mean time he had no discomfort, all laboratory and the physical examination findings were normal, as well as the ECG. Echocardiogram showed normal contractility, systolic and diastolic function. Cardiac stress testing and coronary angiography both ruled out a coronary heart disease. Diagnosis of myocarditis in this case was made based on echocardiogram, anamnestic data and on the typical clinical presentation of an acute varicella zoster virus infection, and was serologically confirmed by ELISA test. Therapy with NSAID was started immediately and because of favorable development of the disease we did not perform myocardial biopsy. During second hospitalization an eventual coronary heart disease was ruled out by coronary angiography. Due to its rarity there are no guidelines regarding therapy of varicella myocarditis, but there is a consensus that these patients should receive intensive care unit. The basis of the therapy are certainly the NSAIDs, but also a combination of acyclovir and hyperimmunoglobulins has been reported which in this mild case was not necessary. With this report we want to point out that varicella zoster virus can cause myopericarditis in immunocompetent adults, which must be taken into consideration in differential diagnosis, and that an early diagnosis and adequate therapy can help achieve a fast and complete recovery.

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