【正文】 Diagnostic approach EKG: ? VPC bigeminy, ventricular tachycardia ? STsegment change Elevated cardiac enzyme Echocardiogram: marked LV dyskinesia Endomyocardial biopsy ? Lymphocyte infiltration ? Myocyte degeneration Acute myocarditis confirmed Clinical classification of myocarditis Fulminant Acute Chronic active Chronic persistent Initial presentation Shock, severe LV dysfuntion CHF CHF Normal LV function Endomyocardial biopsy Multifocal active myocarditis Active or borderline myocarditis Active or borderline myocarditis Active or borderline myocarditis Nature history Complete recovery or death Inplete recovery or DCM DCM Normal LV function Myocarditis: an enigmatic disease! Dark side of the myocarditis Initial nonspecific symptoms Difficult to establish the diagnosis Etiology hard to find Complexity of pathogenesis Often refractory to conventional treatment Dark side of the myocarditis Initial nonspecific symptoms ? Similar to patients with sepsis, bronchiolitis, pneumonia, gastroenteritis, hepatitis, and renal failure etc. ? Aggressive fluid resuscitation may harm unstable patients ? Rapid progression in fulminant myocarditis Dark side of the myocarditis Difficult to establish the diagnosis ? Limited sensitivity and specificity of changes in CXR, ECG, cardiac enzyme (Troponin level: more sensitive) ? Echocardiogram: LV dysfunction, often regional ? Endomyocardial biopsy: as gold standard, but sensitivity 363% Dallas criteria Borderline myocarditis Active myocarditis Am J Cadiovasc Pathol 1987。22:349 Dark side of the myocarditis Complexity of pathogenesis NEJM 2022。 development: ? Weight: 22 kg (3rd10th percentile) ? Height: 130 cm (2550th percentile) ? Development milestone: within normal limit Past history ? Handfootmouth disease in 1998 ? Frequent URI and fever during childhood ? No drug or food allergy Brief History Family history: ? Her sister had fever and URI recently. Present Illness Fever and bilateral hand arthralgia attack once 1 month ago Chest disfort and cough since 9/11 afternoon, 2022 Visit LMD and URI was told Vomiting and chest tightness on 9/12 0 AM and 5 AM Present Ill