Prolonged febrile syndrome in myocardial infarction – a series of unexpected events

Introduction: Myocardial infarction represents one of the major complications of atherosclerosis, with a high risk of mortality.This is the case of a patient diagnosed with myocardial infarction with ST-segment elevation in inferior, posterior and right ventricle wall who despite an early presentation (<2h door-balloon time) was complicated with a complete heart block, acute heart failure and a severe acute febrile syndrome which laid important diagnostic and treatment issues.
Case presentation: 56-year-old male, smoker (40PA), without personal or family history of cardiovascular disease, presented to the emergency department with resting angina of 1.5h duration. He is diagnosed with myocardial infarction with ST-segment elevation in inferior-posterior and right ventricle wall Killip class III. Coronarography shows two vessel coronary artery disease, critical stenosis of OM1 but with TIMI3 flow and right coronary artery with severe atherosclerosis and thrombosis in medial-distal segment and 50-60% stenosis in the ostial segment. This lesion underwent primary percutaneous coronary intervention by deployment of multiple drug-eluting stents with a mediocre final outcome, TIMI 2-3 flow, with thrombosis in the distal segment. Eptifibatide perfusion was started according to STEMI guidelines. In the course of the procedure, after de culprit vessel was opened, the patient developed complete heart block with hemodynamic instability, thus a transvenous temporary pacemaker was inserted and inotropic agents were administered. The temporary pacemaker was removed after 3 days. The patient persisted in asymptomatic complete heart block and narrow QRS complexes with further resolution. Bedside echocardiography showed severe biventricular dysfunction, moderate mitral regurgitation, with further improvement, without pericardial effusion. In the fifth day of hospitalization the patient presents with an acute febrile syndrome, without alveolar condesation, without urinary symptoms with a chest x-ray whi-ch showed peri-bronchial cuffing and perihilar haze, with right pleural effusion in small quantity, reason why in the circumstances of a transvenous temporary pacemaker raised questions regarding the etiology of the infection. The fever is vesperal, multi-drug resistant and with negative blood cultures. The transesophageal echocardiographic ruled out infectious endocarditis, but its images raised the suspicion of descending aorta dissection with posterior wall haematoma. Computed tomography angiography chest-abdomen was performed immediately and the diagnosis of aortic dissection was ruled out and two important findings were made instead:
First: severe atherosclerosis extended in all the arterial system scanned, without haemodynamically significant stenosis.
Second: the etiology of the fever, as it showed right basal pneumonia which was finally responsive to the combination of piperacilline/tazobactam with resolution of the fever, inflammatory syndrome and leukocytosis.
Case particularity: T he investigation of a prolonged febrile syndrome in a young patient with acute myocar-dial infarction with ST-segment elevation in inferior-posterior and right ventricle wall, with just one known cardiovascular risk factor, mediocre angioplasty outcome, complicated with complete heart block and a temporary cardiac stimulation need, which all led to the diagnosis of a severe systemic atherosclerosis.
Conclusion: The severe fever syndrome led to investigations which in the end diagnosed severe systemic atherosclerosis, slow evolution in the short term, with reserved prognosis in the long term. From a treatment and interventional point of view, the patient had received maximum treatment at that moment. The control of cardiovascular risk factors is essential. So the question that raises now, will immune-modulating therapies be an option for this kind patients in the future?

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)