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Objectives: To compare the repeatability and interrelation of various late gadolinium enhancement (LGE) assessment techniques for monitoring fibrotic changes in myocarditis follow-up., Materials and Methods: LGE extent change between baseline and 3-month cardiovascular magnetic resonance (CMR) was compared in patients with acute myocarditis using the full width at half maximum (FWHM), gray-scale thresholds at 5 and 6 standard deviations (SD5 and SD6), visual assessment with threshold (VAT) and full manual (FM) techniques. In addition, visual presence score (VPS), visual transmurality score (VTS), and a simplified visual change score (VCS) were assessed. Intraclass-correlation (ICC) was used to evaluate repeatability, and methods were compared using Spearman's correlation., Results: Forty-seven patients (38 male, median age: 27 [IQR: 21; 38] years) were included. LGE extent change differed among quantitative techniques (p < 0.01), with variability in the proportion of patients showing LGE change during follow-up (FWHM: 62%, SD5: 74%, SD6: 66%, VAT: 43%, FM: 60%, VPS: 53%, VTS: 77%, VCS: 89%). Repeatability was highest with FWHM (ICC: 0.97) and lowest with SD5 (ICC: 0.89). Semiquantitative scoring had slightly lower values (VPS ICC: 0.81; VTS ICC: 0.71). VCS repeatability was excellent (ICC: 0.93). VPS and VTS correlated with quantitative techniques, while VCS was positively associated with VPS, VTS, VAT, and FM, but not with FWHM, SD5, and SD6., Conclusion: FWHM offers the least observer-dependent LGE follow-up after myocarditis. VPS, VTS, and VCS are practical alternatives, showing reliable correlations with quantitative methods. Classification of patients exhibiting either stable or changing LGE relies on the assessment technique., Clinical Relevance Statement: This study shows that LGE monitoring in myocarditis is technique-dependent; the FWHM method yields the most consistent fibrotic tracking results, with scoring-based techniques as reliable alternatives., Key Points: Recognition of fibrotic changes during myocarditis follow-up is significantly influenced by the choice of the quantification technique employed. The FWHM technique ensures highly repeatable tracking of myocarditis-related LGE changes. Segment-based visual scoring and the simplified visual change score offer practical, reproducible alternatives in resource-limited settings., (© 2024. The Author(s).)

Background: The acquisition of contrast-enhanced T1 maps to calculate extracellular volume (ECV) requires contrast agent administration and is time consuming. This study investigates generative adversarial networks for contrast-free, virtual extracellular volume (vECV) by generating virtual contrast-enhanced T1 maps., Methods and Results: This retrospective study includes 2518 registered native and contrast-enhanced T1 maps from 1000 patients who underwent cardiovascular magnetic resonance at 1.5 Tesla. Recent hematocrit values of 123 patients (hold-out test) and 96 patients from a different institution (external evaluation) allowed for calculation of conventional ECV. A generative adversarial network was trained to generate virtual contrast-enhanced T1 maps from native T1 maps for vECV creation. Mean and SD of the difference per patient (ΔECV) were calculated and compared by permutation of the 2-sided t test with 10 000 resamples. For ECV and vECV, differences in area under the receiver operating characteristic curve (AUC) for discriminating hold-out test patients with normal cardiovascular magnetic resonance versus myocarditis or amyloidosis were tested with Delong's test. ECV and vECV showed a high agreement in patients with myocarditis (ΔECV: hold-out test, 2.0%±1.5%; external evaluation, 1.9%±1.7%) and normal cardiovascular magnetic resonance (ΔECV: hold-out test, 1.9%±1.4%; external evaluation, 1.5%±1.2%), but variations in amyloidosis were higher (ΔECV: hold-out test, 6.2%±6.0%; external evaluation, 15.5%±6.4%). In the hold-out test, ECV and vECV had a comparable AUC for the diagnosis of myocarditis (ECV AUC, 0.77 versus vECV AUC, 0.76; P =0.76) and amyloidosis (ECV AUC, 0.99 versus vECV AUC, 0.96; P =0.52)., Conclusions: Generation of vECV on the basis of native T1 maps is feasible. Multicenter training data are required to further enhance generalizability of vECV in amyloidosis.

Background: Detecting ongoing inflammation in myocarditis patients has prognostic relevance, but there are limited data on the detection of chronic myocarditis and its differentiation from healed myocarditis., Objectives: This study sought to assess the performance of cardiac magnetic resonance (CMR) for the detection of ongoing inflammation and the discrimination of chronic myocarditis from healed myocarditis., Methods: Consecutive patients with persistent symptoms (>30 days) suggestive of myocarditis were prospectively enrolled from a single tertiary center. All patients underwent a multiparametric 1.5-T CMR protocol including biventricular strain, T 1 /T 2 mapping, and late gadolinium enhancement (LGE). Endomyocardial biopsy was chosen for the reference standard diagnosis., Results: Among 452 consecutive patients, 103 (median age: 50 years; 66 men) had evaluable CMR and cardiopathologic reference diagnosis: 53 (51%) with chronic lymphocytic myocarditis and 50 (49%) with healed myocarditis. T 2 mapping as a single parameter showed the best accuracy in detecting chronic myocarditis, if abnormal in ≥3 segments (92%; 95% CI: 85-97), and provided the best discrimination from healed myocarditis, as defined by the area under the receiver-operating characteristic curve (0.87 [95% CI: 0.79-0.93]; P < 0.001), followed by radial peak systolic strain rate of the left ventricle (0.86) and the right ventricle (0.84); T 1 mapping (0.64), extracellular volume fraction (0.62), and LGE (0.57). Specificity increased when T 2 mapping was combined with elevation of either troponin or C-reactive protein., Conclusions: A multiparametric CMR protocol allows detection of ongoing myocardial inflammation and discrimination of chronic myocarditis from healed myocarditis, with segmental T 2 mapping and biventricular strain analysis showing higher diagnostic accuracy compared with T 1 mapping, extracellular volume fraction, and LGE. The use of biomarkers (troponin or C-reactive protein) may improve specificity., Competing Interests: Funding Support and Author Disclosures This study was supported by the Deutsche Forschungsgemeinschaft (German Research Foundation), project number 374031971–TRR 240 (molecular aspects). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Objectives : Diagnosis of myocarditis remains a challenge in clinical practice; however, magnetic resonance imaging (CMRI) can ease the diagnostic approach by providing various parameters. The prevalence of right ventricular involvement in acute myocarditis is suggested to be more frequent than previously hypothesized. In this study, we sought to investigate subclinical RV involvement in patients with acute myocarditis and preserved RV ejection fraction (EF), using CMRI RV speckle-tracking imaging. Materials and Methods : CMRI of 27 patients with acute myocarditis (nine females, age 35.1 ± 12.2 y) was retrospectively analyzed. A control group consisting of CMRI images of 27 healthy individuals was included. Results : No significant differences were found regarding left ventricle (LV) and atrium dimensions. LV ejection fraction was significantly different between groups (56.6 ± 10.6 vs. 62.1 ± 2.6, p < 0.05). No significant differences were present between parameters used for conventional assessment of RV. However, RV strain absolute values were significantly lower in the acute myocarditis group in comparison with that of the control group (18.4 ± 5.4 vs. 21.8 ± 2.8, p = 0.018). Conclusions : Subclinical RV dysfunction detected by CMR-derived strain may be present in patients with acute myocarditis even with preserved RVEF.

Introduction and Objective: Multiple studies showed that patients with a severe course of COVID-19 may develop cardiovascular complications. Assessment of the incidence of myocardial injury in young, physically fit male patients with no comorbidities, and asymptomatic/mild course of the disease who recovered from COVID-19., Material and Methods: A prospective, single-center, observational cohort study of 75 young (median[IQR] age 22 years) physically fit male patients, without comorbidities and smoking who recently recovered from COVID-19. Results were compared with a control group of age-matched, physically fit men with no comorbidities who tested negative for SARS-CoV-2., Results: 19(25%) patients had possible COVID-19 related myocardial injury[PCRMI] on cardiovascular magnetic resonance [CMR] including definitive myocarditis (n=1;1.3%) and possible myocarditis (n=3;4%). Other abnormalities: mildly decreased (<50%) left ventricular(LV) ejection fraction (n=4;5%), increased LV end-diastolic volume index (n=8;11%) and LV mass index (n=9;12%). Patients with PCRMI had higher NT-pro-BNP level (29 vs 20pg/mL respectively, P=0.02) and lower LV ejection fraction (55% vs 59% respectively, P=0.03). PCRMI was demonstrated in 3(27%) volunteers from the control group based on the presence of LGE (2/18%) and decreased LV ejection fraction (1/9%). No volunteer from the control group was diagnosed with definitive or possible myocarditis., Conclusions: PCRMI was a frequent finding in young, asymptomatic, physically-fit patients sans comorbidities relatively late after recovery from COVID-19. Whereas no definitive or possible myocarditis was found in the control group, LGE was relatively frequent suggesting that our findings might not be COVID-19 specific. This warrants a need for further investigation into the long-term cardiovascular consequences of COVID-19.

Background: Identifying markers associated with adverse events after acute myocarditis (AM) is relevant to plan follow-up. We assessed the prognostic performance of previously described cardiac magnetic resonance imaging (CMRI) markers and their combination: septal late gadolinium enhancement (LGE) localization and left ventricular ejection fraction (LVEF) < 50 % on baseline CMRI versus complicated clinical presentation (CCP: the presence of sustained ventricular tachycardia, or LVEF<50 % on the first echocardiogram or fulminant presentation)., Methods: We retrospectively assessed 248 AM patients (median age of 34 years, 87.1 % male) from 6 hospitals with onset of cardiac symptoms<30 days, increased troponin, and CMRI/histology consistent with myocarditis to identify those at risk of major cardiac events (cardiac death, heart transplantation, aborted sudden cardiac death, sustained ventricular tachycardia, or heart failure hospitalization)., Results: Thirteen patients (5.2 %) experienced at least one major cardiac event after a median follow-up of 4.7 years with a significant hazard ratio of 35.8 for CCP vs. 9.2 for septal LGE vs. 12.4 for LVEF<50 % on baseline CMRI (p = 0.001). CCP had the best c-index to identify patients with events: 0.836 vs. 0.786 for septal LGE and 0.762 for LVEF<50 %, while the combination of CCP plus LVEF<50 % or septal LGE has the highest c-index of 0.866. All 3 markers had high negative predictive value (NPV) of ≥0.98., Conclusions: Major cardiac events after an AM are relatively low, and CCP, septal LGE, and LVEF<50 % are significantly associated with events. These markers have especially high NPV to identify patients without events after an AM. These observations can help clinicians to monitor the patients after an AM., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Purpose: To assess myocardial injury using rest single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with COVID-19 and to evaluate whether myocardial injury detected by rest MPI predict the prognosis of symptoms after 6 months follow-up., Methods: Patients suspected of myocarditis between December 2022 and March 2023, after the lifting of COVID-19 pandemic restrictions, and between December 2018 and March 2019, prior to the pandemic, were referred to our study. All patients underwent rest MPI. One hundred and sixty four patients with COVID-19 infection after the lifting of pandemic restrictions and 101 patients before the pandemic were included as the study and control groups, respectively. One hundred and fifty three patients of the study group and 83 of the control group presented symptoms when they initially visit to our department. Compare the parameters of myocardial injury detected by rest SPECT MPI between the two groups and then investigate the association between myocardial injury and symptom prognosis in symptomatic patients of both groups., Results: Total perfusion defect (TPD) (4.2% ± 3.3% vs. 2.3% ± 2.2%, P < 0.001), summed rest score (SRS) (5.3 ± 5.4 vs. 2.7 ± 2.0, P < 0.001), the proportion of patients with TPD > 4% (43.3% vs. 17.8%, P < 0.001), TPD > 10% (6.71% vs 0, P < 0.001), SRS > 4 (40.2% vs 15.8%, P < 0.001), SRS > 10 (12.8% vs 0, P < 0.001), the number of abnormal perfusion segments (3.9 ± 3.1 vs. 2.4 ± 1.7, P < 0.001) were all significantly higher in the study group. All the parameters of rest MPI were not associated with the prognosis of symptoms in symptomatic patients of both groups after 6 months follow-up., Conclusion: Myocardial injury in COVID-19 patients could be assessed by rest SPECT MPI. The COVID-19 patients could exhibited a higher frequency and greater severity of myocardial injury than uninfected control patients. Myocardial injury assessed by rest MPI did not predict for the prognosis of symptoms in symptomatic patients of both COVID-19 patients and uninfected patients., (© 2024. The Author(s) under exclusive licence to The Japanese Society of Nuclear Medicine.)

A wide variety of non-invasive and invasive techniques for SCD risk stratification in non ischemic cardiomyopathy (NICM) have been proposed, including left ventricular (LV) ejection fraction, QRS duration, late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and invasive electrophysiologic study with or without three-dimensional electroanatomic mapping (3D-EAM), to identify and characterize the arrhythmogenic substrate. There is still no clear consensus on the risk stratification in this clinical setting. The aim of our study is to characterize the 3D-EAM substrate in patients with the same clinical presentation of unexplained complex VAs and NICM using CMR, three-dimensional electranatomic mapping (3D-EAM) in association with endomyocardial biopsy (EMB) and genetic screening, as a more precise and early diagnostic assessment may provide important subsequent prognostic impact. The study was designed as a prospective multi-center observational evaluation and the patient follow-up was scheduled at 6 months interval. We enrolled 125 patients distinct into four different group by complete diagnostic work-up: myocarditis, non-dilated left ventricular cardiomyopathy, arrhythmogenic cardiomyopathy and control group. The four groups were compared in terms of clinical, imaging and 3D-EAM data. At multivariate analysis sustained VT/VF on admission [HR: 3.64 (1.79-7.4), p < 0.001], total bipolar scar area of left and right ventricle detected by 3D-EAM [HR: 2.24 (1.13-4.49), p = 0.02], histological diagnosis of myocarditis by 3D-EAM guided endomyocardial biopsy (EBM) [HR: 2.79 (1.04-7.44), p = 0.01] were independent predictors of complex VAs or death at follow-up. 3D-EAM guided EMB represent not only a valid diagnostic tool to identify the arrhythmogenic substrate in patients with NICM and ventricular arrhythmic phenotype but also an important predictor of complex Vas at long term follow-up., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Background: This prospective multicenter study assessed the prevalence of myocardial injury in patients with COVID-19 using cardiac magnetic resonance imaging (CMR)., Methods and Results: We prospectively screened 505 patients with moderate to severe COVID-19 disease from 7 hospitals in Japan. Of these patients, 31 (mean [±SD] age 63.5±10.4 years, 23 [74%] male) suspected of myocardial injury, based on elevated serum troponin or B-type natriuretic peptide concentrations either upon admission or 3 months after discharge, underwent CMR 3 months after discharge. The primary endpoint was the presence of myocardial injury, defined by any of the following: (1) contrast enhancement in the left or right ventricle myocardium on late gadolinium enhancement CMR; (2) left or right ventricular dysfunction (defined as <50% and <45%, respectively); and (3) pericardial thickening on contrast enhancement. The mean (±SD) duration between diagnosis and CMR was 117±16 days. The primary endpoint was observed in 13 of 31 individuals (42%), with 8 (26%) satisfying the modified Lake Louise Criteria for the diagnosis of acute myocarditis., Conclusions: This study revealed a high incidence of myocardial injury identified by CMR in patients with moderate to severe COVID-19 and abnormal findings for cardiac biomarkers.

This case report describes a 40-year-old male patient with severe cardiac failure due to eosinophilic granulomatosis with polyangiitis (EGPA) and myocarditis. The fast diagnostic approach with cardiac MRI (CMR) and immunosuppressive treatment with glucocorticoid and cyclophosphamide near-normalized the patient's cardiac function. Myocarditis due to EGPA is rare, however life-threatening, so a systematic approach and early CMR should be considered in patients with known asthma presenting with eosinophilia and cardiac involvement., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Background: Acute necrotizing encephalopathy (ANE) and myocarditis are both acute, life-threatening conditions that can be triggered by COVID-19. We report a case of sequential ANE and myocarditis following a COVID-19 infection., Case Presentation: A 27-year-old female patient was brought to the emergency department due to episodes of fever for two days and a 9-h altered state of consciousness. Her condition rapidly developed into stuporous and hemodynamic instability within serval hours. Veno-arterial extracorporeal membrane oxygenation (ECMO) was rapidly initiated with other supportive treatments. The following-up MRI showed bilateral, symmetrically distributed lesions in the brainstem, bilateral hippocampal regions, and bilateral basal ganglia, consistent with ANE. The diagnosis was confirmed through the detection of SARS-CoV-2 and the exclusion of other potential causes. After weeks of medical treatment, her condition stabilized, and she was transferred for further rehabilitation treatment., Conclusions: This case study indicates that COVID-19 may simultaneously and rapidly affect the central nervous system and cardiovascular system, leading to poor outcomes. Accurate diagnosis and timely invasive bridging therapy, when necessary, can be lifesaving. Further exploration of potential mechanisms underlying COVID-19 central nervous system (CNS) and cardiovascular system manifestations will be important., (© 2024. The Author(s).)

Myocardial somatostatin PET uptake is observed not only in most patients with acute myocarditis (AM) but also in some oncology patients referred for routine somatostatin PET. This raises concerns about the specificity of somatostatin PET for detecting myocarditis. The current study aims to identify factors associated with the detection of myocardial uptake on somatostatin PET scans recorded for oncology indications and differential PET criteria that characterize myocardial uptake in AM patients. Methods: We analyzed factors associated with the detection of myocardial [ 68 Ga]Ga-DOTATOC uptake in 508 [ 68 Ga]Ga-DOTATOC PET scans from 178 patients, performed for confirmed or suspected oncologic disease (Onc-PET) and PET criteria that could differentiate myocardial [ 68 Ga]Ga-DOTATOC uptake in 31 patients with MRI-ascertained AM (AM-PET) from that in the Onc-PET group. Results: Significant myocardial uptake was detected in 137 (26.9%) Onc-PET scans and was independently associated with somatostatin analog treatment (exp(β), 0.805; 95% CI, 0.728-0.890; P < 0.001) and age (exp(β), 1.005; 95% CI, 1.001-1.009; P = 0.012). A comparable model was selected for predicting the myocardial-to-blood SUV max ratio using somatostatin analog treatment ( P < 0.001) and history of coronary artery disease ( P = 0.022). Myocardial uptake was detected in 12.9% (25/193) of Onc-PET scans from patients treated with somatostatin analogs but in 43.4% (59/136) of untreated patients over the median age of 64 y. Myocardial uptake was apparent in all 31 AM-PET scans, with volume and intensity of uptake dramatically higher than in the 137 Onc-PET scans showing myocardial uptake. A myocardial-to-blood SUV max ratio threshold of 2.20 provided a sensitivity of 87% (27/31) and a specificity of 88% (44/50) for differentiating myocardial uptake between the AM-PET group and an Onc-PET group restricted to patients with clinical characteristics comparable to those of patients in the AM-PET group (≤64 y of age, no coronary artery disease history, and no somatostatin agonists). A myocardial uptake volume threshold of 18 cm 3 provided comparable diagnostic accuracy (sensitivity, 84% [26/31]; specificity, 94% [47/50]). Conclusion: Myocardial uptake was detected in 26.9% of somatostatin PET scans recorded for oncology indications. This rate was decreased by somatostatin analog treatments and increased in older individuals. However, somatostatin PET scans, analyzed with the quantitative criterion of uptake intensity or volume, are able to identify AM and to differentiate it from myocardial uptake of other origins., (© 2024 by the Society of Nuclear Medicine and Molecular Imaging.)

Eosinophilic myocarditis can result in endomyocardial fibrosis affecting both ventricles, leading to restrictive cardiomyopathy. Multimodality imaging is crucial for diagnosis, as demonstrated in this case of a patient presenting with symptoms of heart failure., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Aims: To detect the acute myocardial injury in fulminant myocarditis (FM) survivors after extracorporeal membrane oxygenation (ECMO) and to demonstrate its significant differences from non-FM patients by cardiac magnetic resonance (CMR)., Materials and Methods: This retrospective study enrolled 59 patients with acute myocarditis (AM), including 35 non-FM patients, 24 FM patients, and 54 controls. The peak value of cardiac troponin T (cTnT) was recorded. Tissue parameters, including native T1, extracellular volume (ECV), late gadolinium-enhancement (LGE)%, and T2 by CMR were assessed., Results: The mean age was 35 ± 14 years, and 45.8% of the population were males in the AM group. Patients had higher levels of peak cTnT, peak NT-proBNP and peak C-reactive protein in the FM group (all p<0.05). Comparing with non-FM, the values of T1-based imaging parameters were significantly higher in the FM group (all p<0.05). In contrast, no difference was observed among the two groups in terms of T2 value (p=0.707). The septal area was more frequently involved in FM survivors after ECMO treatment, both in T1 and T2-based images. In addition, the cubic relationship was the relative best fit of LGE% against logcTnT and indicated that cTnT value exceeding 300ng/L exhibited a rapid upward trend of LGE%., Conclusion: Comparing to non-FM, higher myocardial necrosis and fibrosis but similar edema determined by T1 and T2 based imaging was found in FM survivors after ECMO treatment. Furthermore, the inter-ventricular septal area was more frequently involved by acute myocardial injury in FM survivors after ECMO treatment. In addition, LGE% showed an overall increasing trend with cTnT values elevating with rapidly increasing with cTnT exceeding 300 ng/L., (Copyright © 2024. Published by Elsevier Ltd.)

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has led to a diverse pattern of myocardial injuries, including myocarditis, which is linked to adverse outcomes in patients. Research indicates that myocardial injury is associated with higher mortality in hospitalized severe COVID-19 patients (75.8% vs 9.7%). Cardiovascular Magnetic Resonance (CMR) has emerged as a crucial tool in diagnosing both ischaemic and non-ischaemic myocardial injuries, providing detailed insights into the impact of COVID-19 on myocardial tissue and function. This review synthesizes existing studies on the histopathological findings and CMR imaging patterns of myocardial injuries in COVID-19 patients. CMR imaging has revealed a complex pattern of cardiac damage in these patients, including myocardial inflammation, oedema, fibrosis, and ischaemic injury, due to coronary microthrombi. This review also highlights the role of LLC criteria in diagnosis of COVID-related myocarditis and the importance of CMR in detecting cardiac complications of COVID-19 in specific groups, such as children, manifesting multisystem inflammatory syndrome in children (MIS-C) and athletes, as well as myocardial injuries post-COVID-19 infection or following COVID-19 vaccination. By summarizing existing studies on CMR in COVID-19 patients and highlighting ongoing research, this review contributes to a deeper understanding of the cardiac impacts of COVID-19. It emphasizes the effectiveness of CMR in assessing a broad spectrum of myocardial injuries, thereby enhancing the management and prognosis of patients with COVID-19 related cardiac complications., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology.)

Competing Interests: Conflict of interest: None declared.

Background and Objectives : Over the past decade, there has been increasing attention paid to advanced and innovative cardiovascular magnetic resonance (CMR) modalities, such as T1 and T2 mapping, which play a major role in diagnosing diffuse myocardial disease. There is little data summarizing the current evidence regarding the diagnostic accuracy of T1 and T2 mapping, and extracellular volume (ECV) in acute myocarditis. The aim of our study was to select, analyze, and systematically review the recent scientific literature on the diagnostic value of CMR T1 and T2 parametric mapping in clinically suspected acute myocarditis. Materials and Methods : The literature search was performed in the PubMed database. Articles published in the years 2014-2024 were included in the analysis. At the initial stage, 458 articles were reviewed, and 13 exploratory research studies were further analyzed and presented in this systematic literature review. Results : The analysis included 686 patients with clinically suspected myocarditis and 372 subjects in the control group. The average age of patients with suspected myocarditis was 40.25 years; 26% of them were women. Prolonged native myocardial T1 relaxation time provides diagnostic accuracy in the setting of suspected acute myocarditis ranging from 69 to 99%, with sensitivity from 64 to 98% and specificity from 87 to 100%. Diagnostic accuracy of prolonged T2 relaxation time ranges from 47 to 87%, with sensitivity being from 48% to 94% and specificity from 60% to 92%. ECV alone showed moderate diagnostic performance, with diagnostic accuracy ranging from 62% to 76%, sensitivity from 47% to 73%, and specificity from 76% to 90%. T1 and T2 mapping and ECV, combined with the late gadolinium enhancement (LGE) technique, increases the probability of detecting myocardial inflammatory changes at various stages of the disease, improving the diagnostic accuracy to 96%. Conclusions : New quantitative CMR techniques, i.e., T1 and T2 mapping, have an advantage over conventional CMR sequences in detecting inflammatory myocardial structural changes and play an important role in diagnosing acute myocarditis. Incorporating these sequences in daily clinical practice increases the diagnostic value of CMR in acute myocarditis and becomes an alternative to endomyocardial biopsy, which has been considered the gold standard until now.

Background: This study assesses the diagnostic utility of strain parameters from cardiovascular magnetic resonance feature tracking across all cardiac chambers in patients with acute myocarditis, stratified by ejection fraction., Methods and Results: Our cohort included 65 patients with acute myocarditis and 25 healthy controls; all underwent cardiac magnetic resonance imaging. Patients were divided into 2 groups based on left ventricular ejection fraction (EF)with a 55% cutoff: acute myocarditis with preserved EF, EF ≥55%, n=48; and acute myocarditis with reduced EF, EF <55%, n=17. The control group matched for age and sex. Cardiovascular magnetic resonance feature tracking evaluated strain parameters across all cardiac chambers. Both acute myocarditis with preserved EF and acute myocarditis with reduced EF groups showed significant decreases in left atrial peak early negative strain rate compared with controls. The acute myocarditis with reduced EF group had significantly reduced left ventricular circumferential strain relative to acute myocarditis with preserved EF and controls. Receiver operating characteristic curve analysis confirmed the diagnostic accuracy in distinguishing patients with acute myocarditis with preserved EF from controls, with left atrial peak early negative strain rate achieving 92.9% specificity, left ventricular circumferential strain demonstrating an area under the curve of 0.832, and similarly effective results for left ventricular longitudinal strain and right ventricular longitudinal strain. Additionally, left atrial peak early negative strain rate and left ventricular circumferential strain showed significant correlations with troponin I levels, indicating myocardial injury., Conclusions: Cardiovascular magnetic resonance feature-tracking-derived strain parameters, particularly left atrial peak early negative strain rate and left ventricular circumferential strain, effectively diagnose acute myocarditis across different EFs, enhancing diagnostic accuracy and facilitating early detection, notably in patients with preserved EF.

Cardiac involvement in idiopathic inflammatory myopathies (IIM) purports to worse clinical outcomes, and therefore early identification is important. Research has focused on blood biomarkers and basic investigations such as ECG and echocardiography, which have the advantage of wide availability and low cost but are limited in their sensitivity and specificity. Imaging the myocardium to directly look for inflammation and scarring has therefore been explored, with a number of new methods for doing this gaining wider research interest and clinical availability. Cardiovascular magnetic resonance (CMR) with contemporary multiparametric mapping techniques and late gadolinium enhancement imaging, is an extremely valuable and increasingly used non-invasive imaging modality for the diagnosis of myocarditis. The recently updated CMR-based Lake Louise Criteria for the diagnosis of myocarditis incorporate the newer T1 and T2 mapping techniques, which have greatly improved the diagnostic accuracy for IIM myocarditis.18F-FDG-PET/CT is a well-utilized imaging modality in the diagnosis of malignancies in IIM, and it also has a role for the diagnosis of myocarditis in multiple systemic inflammatory diseases. Endomyocardial biopsy, however, remains the gold standard technique for the diagnosis of myocarditis and is necessary for the diagnosis of specific cases of myocarditis. This article provides an overview of the important tests and imaging modalities that clinicians should consider when faced with an IIM patient with potential myocarditis., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Introduction and Objectives: The present study sought to establish the diagnostic yield of cardiovascular magnetic resonance (CMR) in a large cohort of patients admitted with myocardial infarction (MI) with nonobstructive coronary artery disease (MINOCA) based on the timing of referral to CMR., Methods: Consecutive patients referred to CMR from January 2009 to February 2022 with a working diagnosis of MINOCA were retrospectively evaluated. Cine, T 2 -weighted, early, and late gadolinium-enhanced images were acquired and analyzed. The frequency of the underlying diagnosis and the association between timing of CMR and relative frequency of each diagnosis were assessed., Results: We included 207 patients (median age 50 years, 60% men). Final diagnosis after CMR was achieved in 91% of the patients (myocarditis in 45%, MI in 20%, tako-tsubo cardiomyopathy in 19%, and other cardiomyopathies in 7%). The performance of CMR within 7 days of admission with MINOCA (median, 5 days; 117 patients) allowed a higher diagnostic yield compared with CMR performed later (median, 10 days; 88 patients) (96% vs 86%, P=.02). Although myocarditis was the most frequent diagnosis in both groups according to time to CMR, its frequency was higher among patients with a CMR performed within the first 7 days (53% vs 35%, P=.02). The frequency of other underlying diagnoses was not influenced by CMR timing., Conclusions: CMR led to an underlying diagnosis of MINOCA in 91% of patients and its diagnostic yield increased to 96% when CMR was performed within 7 days of admission. The most frequent diagnosis was myocarditis.., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose of the Review: Cardiac involvement in systemic sarcoidosis or isolated cardiac sarcoidosis plays a pivotal role in the clinical manifestation and prognostication. Active-inflammatory cardiac sarcoidosis is associated with a regional impairment of coronary microvascular function that may confer further detrimental effects on myocardial function needing further characterization., Recent Findings: Clinical investigations with cardiac positron emission tomography/computed tomography in conjunction with 18 F-fluorodeoxyglucose to determine myocardial inflammation and 13 N-ammonia to quantify myocardial blood flow (MBF) in patients with known or suspected cardiac sarcoidosis outlined that sarcoidosis-induced myocardial inflammation was associated with adverse effects on corresponding regional coronary microvascular function. Notably, immune-suppressive treatment caused reductions in myocardial inflammation were paralleled by improvements of coronary microvascular dysfunction outlining direct adverse effect of inflammation on coronary arteriolar function. This review summarizes contributions of cardiac PET imaging in the identification and characterization of active-inflammatory cardiac sarcoidosis, its effect on coronary microvascular function, treatment responses, and prognostic implications., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Myocarditis is an overlooked manifestation of anti-synthetase syndrome (ASS). Our study describes the clinical and instrumental features of ASS myocarditis and evaluates the performance of cardiac MRI (CMRI) with mapping techniques in assisting diagnosis of ASS myocarditis., Methods: Data from patients with ASS were retrospectively analysed. CMRI data for patients diagnosed with myocarditis, including late gadolinium enhancement (LGE), T2 ratio, T1 mapping, extracellular volume (ECV) and T2 mapping, were reviewed. Myocarditis was defined by the presence of symptoms and/or signs suggestive for heart involvement, including increased high-sensitive troponin T (hs-TnT) and/or N-terminal pro-brain natriuretic peptide (NT-proBNP), and at least an instrumental abnormality. The clinical features of patients with ASS with and without myocarditis were compared. A P-value of <0.05 was considered statistically significant., Results: Among a cohort of 43 patients with ASS [median age 58 (48.0-66.0) years; females 74.4%; anti-Jo1 53.5%], 13 (30%) were diagnosed with myocarditis. In 54% of those 13 patients, myocarditis was diagnosed at clinical onset. All patients with ASS with myocarditis had at least one CMRI abnormality: increased ECV in all cases, presence of LGE in 91%, and increased T1 and T2 mapping in 91%. The 2009 Lake Louise criteria (LLC) were satisfied by 6 patients, and the 2018 LLC by 10 patients. With the updated LLC, the sensitivity for myocarditis improved from 54.6% to 91.0%. Patients with ASS with myocarditis were more frequently males (53% vs 13%; P = 0.009) with fever (69% vs 17%; P = 0.001), and had higher hs-TnT [88.0 (23.55-311.5) vs 9.80 (5.0-23.0) ng/l; P < 0.001], NT-proBNP [525.5 (243.5-1575.25) vs 59.0 (32.0-165.5; P = 0.013) pg/ml; P = 0.013] and CRP [7.0 (1.7-15.75) vs 1.85 (0.5-2.86) mg/l; P = 0.011] compared with those without myocarditis., Conclusion: In ASS, myocarditis is frequent, even at clinical onset. Patients with ASS with myocarditis frequently presented with fever and increased CRP, suggesting the existence of an inflammatory phenotype. The use of novel CMRI mapping techniques may increase diagnostic sensitivity for myocarditis in ASS., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Aims: To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through a European Association of Cardiovascular Imaging survey., Methods and Results: A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres (56%). All participants had access to echocardiography, while 79 and 75% had access to cardiac computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half (47%) had access to myocardial biopsy, and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischaemic late gadolinium enhancement (LGE, 88%) and high-signal intensity in T2-weighted images (74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and angiotensin-converting enzyme inhibitors was reported by 38 and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction (89%), followed by LGE regression (60%). In two-thirds of participants, the decision to resume high-intensity sport was influenced by residual LGE., Conclusion: This survey confirms the high utilization of cardiac imaging in AM but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The treatment of choice for Extra-osseous Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET), a rare neoplasm, is the VAC/IE regimen. This regimen includes Doxorubicin, Vincristine, Cyclophosphamide, Ifosfamide, and Etoposide, all of which have cardiotoxic effects. Myocarditis, a potentially threatening side effect following cancer therapy, can be accurately managed and diagnosed., Case Presentation: In the current study, we report the case of a 19-year-old female with a mass on the abdominal wall, diagnosed with ES/PNET. She was treated with the VAC/IE regimen. A month after the last session of chemotherapy, she experienced dyspnea. Upon evaluation, a high level of troponin and a low left ventricular ejection fraction (LVEF) were detected via transthoracic echocardiography. She was treated with anti-heart failure drugs, but the response was unsatisfactory. The possibility of Cancer therapy-related myocarditis was suspected, and cardiac magnetic resonance imaging (CMR) confirmed acute myocarditis. This patient exhibited a significant response to intravenous immunoglobulin (IVIG), with her LVEF improving from 30-35% to 50% within three months., Conclusion: In this case, based on negative tests and the absence of viral signs and symptoms, Cancer therapy-related myocarditis is highly suspected as the cause of myocarditis. This case underscores the importance of accurately utilizing CMR as a non-invasive method for diagnosing myocarditis. It effectively highlights the identification of reversible myocarditis with appropriate treatment and the notable response to IVIG, suggesting its potential as a favorable treatment for myocarditis in younger patients., (© 2024. The Author(s).)

Imaging strategies for the specific detection and therapeutic monitoring of myocarditis are still lacking. Stimulator of interferon genes (STING) is a signal transduction molecule involved in an innate immune response. Here, we evaluated the feasibility of the recently developed STING-targeted radiotracer [ 18 F]FBTA for positron emission tomography (PET) imaging to detect myocardial inflammation and monitor treatment in myocarditis mice. [ 18 F]FBTA-PET imaging was performed in myocarditis mice and normal mice to verify the specificity of [ 18 F]FBTA for the diagnosis of myocarditis. We also performed PET imaging in mice with myocarditis treated to verify the ability of [ 18 F]FBTA in therapeutic monitoring. The expression of STING and inflammatory cell types was confirmed by flow cytometry and immunohistochemistry. [ 18 F]FDG-PET imaging of myocarditis was used as a contrast. [ 18 F]FBTA-PET imaging showed that the average radioactive uptake was significantly higher in the hearts of the myocarditis group than in the control group. STING was highly overexpressed in cardiac inflammatory cells, including macrophages, dendritic cells (DCs), and T cells. However, there was no significant difference in cardiac radiotracer uptake of [ 18 F]FDG between the myocarditis group and the control group. Moreover, cardiac uptake of [ 18 F]FBTA was significantly reduced in cyclosporin A-treated myocarditis mice and myocardial STING expression was also significantly reduced after the treatment. Overall, we showed that a STING-targeted PET tracer [ 18 F]FBTA can be used to monitor changes in the inflammatory microenvironment in myocarditis. Besides, [ 18 F]FBTA-PET is also suitable for real-time monitoring of myocarditis treatment, representing a promising diagnostic and therapeutic monitoring approach for myocarditis.

Cardiovascular magnetic resonance T1 and T2 mapping reflects inflammation, fibrosis, and myocardial oedema. However, its application in infants remains uncertain. Herein, we report a three-month-old boy with dilated cardiomyopathy successfully treated with steroids. Cardiovascular magnetic resonance was useful for diagnosis based on the elevated native T1, T2, and extracellular volume and evaluation of response to immunosuppressive therapy in infantile inflammatory dilated cardiomyopathy.

We present a case of a young patient with chest pain. Labs and cardiac imaging were suspicious for acute myocarditis. Genetic testing revealed a diagnosis of desmoplakin cardiomyopathy. Desmoplakin cardiomyopathy may be considered in patients with recurrent acute myocarditis or a family history of cardiac disease to avoid the potential for misdiagnosis., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Acute myocarditis usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favourable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders, and is considered the leading cause of sudden cardiac death in young, apparently healthy, adults. There are no specific recommendations for acute myocarditis diagnosis and management, only expert consensus, given the lack of large databases., Aim: The main objective is to describe the contemporary presentation of acute myocarditis, its management and in-hospital outcomes. Secondary objectives are to investigate survival and event-free survival for up to 10years of follow-up, the determinants of prognosis, the modalities of treatment and follow-up and the gaps between expert consensus and real-life management., Methods: MyocarditIRM is a prospective multicentre cohort that enrolled 803 consecutive patients with acute myocarditis in 49 participating centres in France between 01 May 2016 and 28 February 2019. The diagnosis of acute myocarditis was acknowledged by cardiac magnetic resonance, using the Lake Louise Criteria. Exclusion criteria were age<18years, lack of health coverage, contraindication to cardiac magnetic resonance and refusal to participate. Detailed information was collected prospectively, starting at admission. Cardiac magnetic resonance imaging (diagnosis and follow-up) is analysed centrally by the certified core laboratory IHU ICAN. Ten years of follow-up for each patient is ensured by linking with the French National Health Database, and includes information on death, hospital admissions, major clinical events and drug consumption., Conclusion: This prospective cohort with long-term follow-up represents the largest database on acute myocarditis worldwide, and will improve knowledge about its presentation, management and outcomes., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: The purpose of this study was to evaluate cardiovascular magnetic resonance (CMR) findings and their relationship to longer-term clinical outcomes in patients with suspected myocarditis following coronavirus disease 2019 (COVID-19) vaccination., Methods: Consecutive adult patients who underwent clinically indicated CMR for evaluation of suspected myocarditis following messenger ribonucleic acid (mRNA)-based COVID-19 vaccination at a single center between 2021 and 2022 were retrospectively evaluated. Patients were classified based on the revised Lake Louise criteria for T1-based abnormalities (late gadolinium enhancement [LGE] or high T1 values) and T2-based abnormalities (regional T2-hyperintensity or high T2 values)., Results: Eighty-nine patients were included (64% [57/89] male, mean age 34 ± 13 years, 38% [32/89] mRNA-1273, and 62% [52/89] BNT162b2). On baseline CMR, 42 (47%) had at least one abnormality; 25 (28%) met both T1- and T2-criteria; 17 (19%) met T1-criteria but not T2-criteria; and 47 (53%) did not meet either. The interval between vaccination and CMR was shorter in those who met T1- and T2-criteria (28 days, IQR 8-69) compared to those who met T1-criteria only (110 days, IQR 66-255, p < 0.001) and those who did not meet either (120 days, interquartile range (IQR) 80-252, p < 0.001). In the subset of 21 patients who met both T1- and T2-criteria at baseline and had follow-up CMR, myocardial edema had resolved and left ventricular ejection fraction had normalized in all at median imaging follow-up of 214 days (IQR 132-304). However, minimal LGE persisted in 10 (48%). At median clinical follow-up of 232 days (IQR 156-405, n = 60), there were no adverse cardiac events. However, mild cardiac symptoms persisted in 7 (12%)., Conclusion: In a cohort of patients who underwent clinically indicated CMR for suspected myocarditis following COVID-19 vaccination, 47% had at least one abnormality at baseline CMR. Detection of myocardial edema was associated with the timing of CMR after vaccination. There were no adverse cardiac events. However, minimal LGE persisted in 48% at follow-up., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interests The author declares that she has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Conflict of interest: None declared.

Objective. Myocarditis poses a significant health risk, often precipitated by viral infections like coronavirus disease, and can lead to fatal cardiac complications. As a less invasive alternative to the standard diagnostic practice of endomyocardial biopsy, which is highly invasive and thus limited to severe cases, cardiac magnetic resonance (CMR) imaging offers a promising solution for detecting myocardial abnormalities. Approach. This study introduces a deep model called ELRL-MD that combines ensemble learning and reinforcement learning (RL) for effective myocarditis diagnosis from CMR images. The model begins with pre-training via the artificial bee colony (ABC) algorithm to enhance the starting point for learning. An array of convolutional neural networks (CNNs) then works in concert to extract and integrate features from CMR images for accurate diagnosis. Leveraging the Z-Alizadeh Sani myocarditis CMR dataset, the model employs RL to navigate the dataset's imbalance by conceptualizing diagnosis as a decision-making process. Main results. ELRL-DM demonstrates remarkable efficacy, surpassing other deep learning, conventional machine learning, and transfer learning models, achieving an F-measure of 88.2% and a geometric mean of 90.6%. Extensive experimentation helped pinpoint the optimal reward function settings and the perfect count of CNNs. Significance. The study addresses the primary technical challenge of inherent data imbalance in CMR imaging datasets and the risk of models converging on local optima due to suboptimal initial weight settings. Further analysis, leaving out ABC and RL components, confirmed their contributions to the model's overall performance, underscoring the effectiveness of addressing these critical technical challenges., (© 2024 Institute of Physics and Engineering in Medicine.)

Competing Interests: The author declares no conflict of interest.

Introduction: Myocarditis is a serious condition that carries with it a high rate of morbidity and mortality., Objective: This review highlights the pearls and pitfalls of myocarditis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence., Discussion: Myocarditis is an inflammatory syndrome of myocardium, most often resulting from a viral infection, that can cause life-threatening cardiovascular collapse. It has a highly variable presentation and no widely available specific diagnostic test, making it a challenging diagnosis. Emergency clinicians should obtain an electrocardiogram and perform bedside ultrasound to assess cardiac function. Treatment in the ED is largely supportive, focusing on resuscitation, cardiovascular support, cardiology specialist consultation, and appropriate disposition., Conclusions: An understanding of myocarditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease., Competing Interests: Declaration of competing interest None. No AI program was utilized in the construction of this manuscript., (Published by Elsevier Inc.)

According to updated Lake-Louise Criteria, impaired regional myocardial function serves as a supportive criterion in diagnosing myocarditis. This study aimed to assess visual regional wall motional abnormalities (RWMA) and novel quantitative regional longitudinal peak strain (RLS) for risk stratification in the clinical setting of myocarditis. In patients undergoing CMR and meeting clinical criteria for suspected myocarditis global longitudinal strain (GLS), late gadolinium enhancement (LGE), RWMA and RLS were assessed in the anterior, septal, inferior, and lateral regions and correlated to the occurrence of major adverse cardiac events (MACE), including heart failure hospitalization, sustained ventricular tachycardia, recurrent myocarditis, and all-cause death. In 690 consecutive patients (age: 48.0 ± 16.0 years; 37.7% female) with suspected myocarditis impaired RLS was correlated with RWMA and LV-GLS but not with the presence of LGE. At median follow up of 3.8 years, MACE occurred in 116 (16.8%) patients. Both, RWMA and RLS in anterior-, septal-, inferior-, and lateral- locations were univariately associated with outcomes (all p < 0.001), but not after adjusting for clinical characteristics and LV-GLS. In the subgroup of patients with normal LV function, RWMA were not predictive of outcomes, whereas septal RLS had incremental and independent prognostic value over clinical characteristics (HR adjusted  = 1.132, 95% CI 1.020-1.256; p = 0.020). RWMA and RLS can be used to assess regional impairment of myocardial function in myocarditis but are of limited prognostic value in the overall population. However, in the subgroup of patients with normal LV function, septal RLS represents a distinctive marker of regional LV dysfunction, offering potential for risk-stratification., (© 2024. The Author(s).)

Myocarditis is an important public health issue due to the high prevalence of sudden death in adolescents and young adults. Nevertheless, the early identification of myocarditis remains a serious problem for clinicians. There is no single non-invasive method to diagnose myocarditis in the currently available clinical guidelines and consensus. Molecular imaging is an effective approach for accurate diagnosis. Poly(lactic acid-glycolic acid) (PLGA) is considered to be the preferred carrier for molecular imaging because of its biosafety and modifiability. Macrophage membrane-modified biomimetic nanoprobes (MM-NPs) possess low immunogenicity and inflammation-directed chemotaxis capabilities and are repeatedly chosen as materials for targeted diagnosis and treatment of inflammatory diseases. In this study, experimental autoimmune myocarditis (EAM) was used as an animal model of inflammation. Previous studies have confirmed that this model is similar to pathological injury caused by acute myocarditis in humans. In multimodal imaging (US/PA/MRI), a phase-change material (PFH) and superparamagnetic iron oxide (SPIO) are used as imaging substances. Early identification of myocardial inflammatory sites was achieved by the tail vein injection of MM/NPs loaded with PFH and SPIO. This probe is expected to be a powerful tool for clinicians to diagnose myocarditis.

A woman in her 30s with a medical history of metastatic rectal adenocarcinoma, currently on pembrolizumab, which started a few weeks ago, was admitted for abdominal pain. During the hospital stay, she experienced sharp chest pain. Troponin was 1885 ng/mL which peaked at 7338 ng/mL. ECG was unremarkable. The echocardiogram showed an Ejection fraction (EF) of 55%-60% and basal-inferior wall hypokinesis. Left heart catheterisation showed no coronary abnormalities. Cardiac MRI showed a non-coronary area of focal T1 and T2 hyperintense signal and transmural delayed gadolinium enhancement in the mid-basal inferior/inferoseptal wall consistent with myocardial damage. Pericardium showed increased thickness and adhesions at the right ventricular outflow tract consistent with pericarditis. Steroid therapy was initiated, and a marked clinical response was achieved. Immune checkpoint inhibitor-induced myocarditis and pericarditis is a rare complication associated with a high mortality rate, if untreated. Diagnosis requires a multidisciplinary approach, and early detection is critical to preventing a fatal outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Chlamydia psittaci ‒ related community-acquired pneumonia associated to acute myocarditis was diagnosed in a young man with no medical history, and a professional exposition to birds. The diagnosis was confirmed with positive specific polymerase chain reaction in bronchoalveolar lavage. The patient was treated with spiramycin for two weeks with anti-inflammatory treatment for myocarditis for three months. Clinical and biological improvement was rapidly observed followed by normalization of electrocardiogram and chest CT scan. No relapse was reported for over a two-year follow-up., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U. All rights reserved.)