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Sepsis-Related Myocardial Calcification

2011; Lippincott Williams & Wilkins; Volume: 4; Issue: 5 Linguagem: Inglês

10.1161/circheartfailure.111.962183

1941-3297

Rob C.M. van Kruijsdijk, Joris van der Heijden, Ruben Uijlings, Luuk C. Otterspoor,

Infective Endocarditis Diagnosis and Management

HomeCirculation: Heart FailureVol. 4, No. 5Sepsis-Related Myocardial Calcification Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBSepsis-Related Myocardial Calcification Rob C.M. van Kruijsdijk, MD, Joris J. van der Heijden, MD, Ruben Uijlings, MD and Luuk C. Otterspoor, MD Rob C.M. van KruijsdijkRob C.M. van Kruijsdijk From the Department of Intensive Care (R.C.M.K., L.C.O.) and the Department of Cardiology (J.J.v.d.H.), University Medical Centre, Utrecht, Utrecht, The Netherlands; and the Department of Cardiology (R.U.), Deventer Hospital, Deventer, The Netherlands. , Joris J. van der HeijdenJoris J. van der Heijden From the Department of Intensive Care (R.C.M.K., L.C.O.) and the Department of Cardiology (J.J.v.d.H.), University Medical Centre, Utrecht, Utrecht, The Netherlands; and the Department of Cardiology (R.U.), Deventer Hospital, Deventer, The Netherlands. , Ruben UijlingsRuben Uijlings From the Department of Intensive Care (R.C.M.K., L.C.O.) and the Department of Cardiology (J.J.v.d.H.), University Medical Centre, Utrecht, Utrecht, The Netherlands; and the Department of Cardiology (R.U.), Deventer Hospital, Deventer, The Netherlands. and Luuk C. OtterspoorLuuk C. Otterspoor From the Department of Intensive Care (R.C.M.K., L.C.O.) and the Department of Cardiology (J.J.v.d.H.), University Medical Centre, Utrecht, Utrecht, The Netherlands; and the Department of Cardiology (R.U.), Deventer Hospital, Deventer, The Netherlands. Originally published1 Sep 2011https://doi.org/10.1161/CIRCHEARTFAILURE.111.962183Circulation: Heart Failure. 2011;4:e16–e18IntroductionA 56-year-old man was admitted on our intensive care unit with septic shock after 10 days of diarrhea, shortly after he had visited India. He had no relevant previous medical history. Blood and fecal cultures grew various pathogens, including Shigella flexneri. ECG showed diffuse ST elevation with PR depression (Figure 1), and laboratory results revealed significant troponin (peak level of 5.72 ng/mL) and creatine phosphokinase-MB (peak level of 117 ng/mL) release, most likely caused by a perimyocarditis in the setting of Shigella sepsis. Further diagnostic evaluation revealed hairy cell leukemia. After initial improvement of his clinical condition and treatment with rituximab and prednisolone, he was readmitted to the intensive care unit with respiratory failure and new-onset left ventricular dysfunction as was observed with echocardiography. Compared with the prior tracing, his ECG now showed microvoltages in the extremity leads, this time with normal ST segments (Figure 2). Computed tomographic imaging revealed extensive myocardial calcification of the left ventricle that was not seen on previous computed tomographic images (Figures 3 and 4). Comparable images of a pronounced dense myocardium with normal aspect of the endocardial layer were observed with transesophageal echocardiography (Figure 5). Serum levels of calcium were repeatedly not elevated during the admittance.Download figureDownload PowerPointFigure 1. ECG at day 1 of admission showing diffuse concave ST elevation with PR depression (arrow).Download figureDownload PowerPointFigure 2. ECG at day 31 of admission showing micro voltages in the extremity leads with normal ST segments.Download figureDownload PowerPointFigure 3. Computed tomography scan at day 1 of admission showing normal appearing myocardium. LA indicates left atrium; RA, right atrium; LV, left ventricle; and RV, right ventricle.Download figureDownload PowerPointFigure 4. Computed tomography scan at day 31 of admission showing extensive calcification of the left ventricular myocardium. LA indicates left atrium; RA, right atrium; LV, left ventricle; and RV, right ventricle.Download figureDownload PowerPointFigure 5. Transesophageal echocardiogram (4-chamber view) showing pronounced echodensity of the myocardium of the midseptal, apical, and lateral walls, with a normal endocardial layer. LA indicates left atrium; LV, left ventricle; and RV, right ventricle.Localized myocardial calcification is commonly observed after myocardial infarction. Diffuse calcification, however, is a rare phenomenon. Interestingly, similar cases of extensive left ventricular calcification after a period of severe sepsis have been described previously.1–3 Two different pathophysiological mechanisms resulting in calcium deposition in cardiac myocytes can be distinguished.4 First, significant disturbances in calcium metabolism can lead to metastatic calcification, as is occasionally observed in patients with chronic renal failure. Furthermore, calcium may accumulate in necrotized cardiac myocytes, which is known as dystrophic calcification. The latter mechanism is believed to underlie myocardial calcification in the setting of myocardial infarction and severe sepsis.3,4 At present, no therapies, other than symptomatic treatment of the restrictive cardiomyopathy due to myocardial calcification, are available.DisclosuresNone.FootnotesCorrespondence to L.C. Otterspoor, MD, Cardiologist/Intensivist, University Medical Centre Utrecht, Department of Intensive Care, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail l.c.[email protected]nlReferences1. Rossi MA, Santos CS. Sepsis-related microvascular myocardial damage with giant cell inflammation and calcification. Virchows Arch. 2003; 443:87–92.CrossrefMedlineGoogle Scholar2. Schellhammer F, Ansen S, Arnold G, Brochhagen HG, Lackner K. Myocardial calcification following septic shock. Cardiology. 2002; 98:102–103.CrossrefMedlineGoogle Scholar3. Simonson S, Miller WT, Perl A, Torigian DA. Diffuse left ventricular myocardial calcification in the setting of sepsis on CT imaging. J Thorac Imaging. 2007; 22:343–345.CrossrefMedlineGoogle Scholar4. Catellier MJ, Chua GT, Youmans G, Waller BF. Calcific deposits in the heart. Clin Cardiol. 1990; 13:287–294.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Li B, Liu Q, Chen X, Chen T, Dang W, Zhao J, Cui G, Chen K and Wu Y (2022) A Novel Idiopathic Atrial Calcification: Pathologic Manifestations and Potential Mechanism, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.788958, 9 Yokoi M, Ito T, Wakami K, Sugiura T, Ohte N and Seo Y (2022) Early detection and progression of sepsis-related myocardial calcification with subsequent left ventricular systolic dysfunction: a case report, Journal of Cardiology Cases, 10.1016/j.jccase.2021.07.010, 25:3, (130-132), Online publication date: 1-Mar-2022. 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Roberts W, Rosenblatt R, Ko J, Grayburn P, Kuiper J and Guileyardo J (2014) Cardiac Restriction Secondary to Massive Calcific Deposits in the Left Ventricular Cavity, The American Journal of Cardiology, 10.1016/j.amjcard.2013.12.047, 113:8, (1442-1446), Online publication date: 1-Apr-2014. Mana M, Sanguineti F, Unterseeh T, Bouvier E and Garot J (2012) Petrified Myocardium, Circulation, 10.1161/CIRCULATIONAHA.112.100321, 126:9, (1139-1142), Online publication date: 28-Aug-2012. September 2011Vol 4, Issue 5 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.111.962183PMID: 21934087 Manuscript receivedMarch 11, 2011Manuscript acceptedJune 9, 2011Originally publishedSeptember 1, 2011 Keywordsheart failuresepsismyocardial calcificationimagingcalciumPDF download Advertisement SubjectsComputerized Tomography (CT)Heart Failure