A 45-year-old white female with thalassaemia major, diabetes mellitus and hypogonadism underwent routine cardiac magnetic resonance (CMR) imaging to evaluate T2*, a myocardial and hepatic iron load indicator useful in the management of iron chelating therapy. At cardiac cine imaging, left ventricular antero-apical mild hypokinesia and pericardial effusion were evident. T2 weighted STIR image (fig 1) showed high signal intensity of the left ventricular lateral wall, a typical sign of myocardial oedema. Delayed enhancement imaging after paramagnetic contrast (fig 2) showed intramyocardial enhancement matching with the T2 weighted image. Myocardial T2* was within normal values, suggesting no evidence of myocardial iron overload.
Figure 1. T2 weighted four chamber view showing high signal intensity of the lateral wall (white arrow).
Figure 2. Delay enhancement short axis view showing lateral wall hyperenhancement (white arrow).
A flue-like syndrome a few days before the MR examination was the only significant symptom. The subsequent follow-up was negative for major events.
In thalassaemia major, transfusions and iron chelation therapy have significantly improved patient survival. However, congestive heart failure is still the leading cause of mortality. A direct iron toxic effect on myocardial cells is considered to be the main aetiologic factor of hypokinetic cardiomyopathy, but many other co-morbidities may precipitate cardiac failure. The incidence of infections among thalassaemic patients is higher than in normal controls and is related to the impairment of immune competence and to endocrinopathies such as hypothyroidism and diabetes mellitus.1
Myocarditis is a serious complication related to iron load induced viral infection susceptibility and myocardial vulnerability.2
CMR imaging offers the opportunity to evaluate non-invasively myocardial morphology, function and iron load3 and to detect, as in the present case, an insidious presentation of acute myocarditis.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
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