Dominik S Westphal1, Hannah Krafft2, Ruth Biller3, Karin Klingel4, Jochen Gaa5, Christoph S Mueller6, Eimo Martens7. 1. Department of Internal Medicine I, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany; Institute of Human Genetics, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany. Electronic address: dominik.westphal@mri.tum.de. 2. Department of Electrophysiology, German Heart Center Munich, Technical University Munich, Munich, Germany. 3. ARVC-Selbsthilfe e.V., Unterschleissheim, Germany; European Patient Advocacy Group of the European Reference Network ERN GUARD-Heart, Amsterdam, The Netherlands. 4. Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany. 5. Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany. 6. Herzchirurgische Klinik und Poliklinik, Klinikum der Universitaet Muenchen, Munich, Germany. 7. Department of Internal Medicine I, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany.
Abstract
INTRODUCTION: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is now usually referred to as arrhythmogenic cardiomyopathy (ACM) because of the possible left and biventricular affection. In recent years, it has been shown that early-stage ACM, especially in women carrying a disease-causing variant in the DSP gene, may present with clinical signs of myocarditis. CASE PRESENTATION: The female patient was diagnosed with myocarditis based on arrhythmia and findings on magnetic resonance imaging at the age of 24 years. An additional performed myocardial biopsy confirmed a lymphocytic inflammatory reaction. Subsequently, the patient experienced cardiac arrest because of ventricular fibrillation and was resuscitated. As a result, she received an implantable cardioverter defibrillator, and repeated ablations of recurrent ventricular tachycardia were performed. After four years, molecular genetic testing identified the heterozygous, likely pathogenic nonsense variant c.4789G > T, p.(Glu1597*) in DSP (NM_004415.4). Based on this finding, ACM could be diagnosed, and a heart transplantation was performed only a few months later because of rapid disease progression. DISCUSSION: Truncating variants in DSP have been associated with fulminant progression of arrhythmia. However, the currently used ARVC task force criteria are inadequate to detect DSP-associated ACM with left dominant presentation. Moreover, the initial diagnosis of myocarditis may distract from a more extensive search for other causes. Consequently, in cases of recurrent or unusually prolonged myocarditis, especially if present without detected pathogens, molecular genetic testing should be considered.
INTRODUCTION: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is now usually referred to as arrhythmogenic cardiomyopathy (ACM) because of the possible left and biventricular affection. In recent years, it has been shown that early-stage ACM, especially in women carrying a disease-causing variant in the DSP gene, may present with clinical signs of myocarditis. CASE PRESENTATION: The female patient was diagnosed with myocarditis based on arrhythmia and findings on magnetic resonance imaging at the age of 24 years. An additional performed myocardial biopsy confirmed a lymphocytic inflammatory reaction. Subsequently, the patient experienced cardiac arrest because of ventricular fibrillation and was resuscitated. As a result, she received an implantable cardioverter defibrillator, and repeated ablations of recurrent ventricular tachycardia were performed. After four years, molecular genetic testing identified the heterozygous, likely pathogenic nonsense variant c.4789G > T, p.(Glu1597*) in DSP (NM_004415.4). Based on this finding, ACM could be diagnosed, and a heart transplantation was performed only a few months later because of rapid disease progression. DISCUSSION: Truncating variants in DSP have been associated with fulminant progression of arrhythmia. However, the currently used ARVC task force criteria are inadequate to detect DSP-associated ACM with left dominant presentation. Moreover, the initial diagnosis of myocarditis may distract from a more extensive search for other causes. Consequently, in cases of recurrent or unusually prolonged myocarditis, especially if present without detected pathogens, molecular genetic testing should be considered.