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Littlewood S, Nikolou E, Aziz W, Anderson L. Mesalazine-induced myocarditis in a patient with ulcerative colitis: a case report. Eur Heart J Case Rep 2024; 8:ytae458. [PMID: 39279885 PMCID: PMC11395831 DOI: 10.1093/ehjcr/ytae458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/15/2024] [Accepted: 08/22/2024] [Indexed: 09/18/2024]
Abstract
Background Mesalazine is an established first-line therapy for inflammatory bowel disease (IBD) and remains the mainstay of treatment for mild to moderate ulcerative colitis (UC). Both mesalazine and UC are rare but recognized causes of myopericarditis. Cardiac magnetic resonance (CMR) is a non-invasive method of assessing for myopericarditis. This case reports highlights the importance of early CMR in diagnosis, and management of myocarditis in a patient with IBD. Case summary A 28-year-old male was admitted with a 2-day history of chest pain. Three weeks prior to this presentation, the patient was initiated on mesalazine for UC. Serum troponin T and C-reactive protein were elevated. An echocardiogram showed borderline low left ventricular systolic function (LVEF = 50-55%). A CMR showed extensive patchy late gadolinium enhancement (LGE) in the mid to epicardial basal and mid lateral wall. The findings were consistent with acute myocarditis, and a working diagnosis of mesalazine-induced myocarditis was made. Mesalazine was stopped and guideline-directed anti-inflammatories initiated. Oral prednisolone was also introduced for IBD control. Follow-up CMR at four months showed near complete resolution of LGE. Discussion Myocarditis in the context of IBD may be infective, immune-mediated or due to mesalazine hypersensitivity. Histological conformation was not available in this case. This case report highlights the importance of access to early CMR in order establish the diagnosis and withdrawal of the culprit medication. In the majority of cases, CMR will replace the need for endomyocardial biopsy; however, this may still be required in the most severe cases.
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Affiliation(s)
- Simon Littlewood
- School of Biomedical Engineering and Image Science, King's College London, 3rd Floor Lambeth Wing, St Thomas' Hospital, London SE1 7EH, United Kingdom
- Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Evgenia Nikolou
- Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Waqar Aziz
- Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Lisa Anderson
- Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
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Appala N, Veeramachaneni H, Khare A, Sundar P. Achy Breaky Heart: A Rare Case of Myopericarditis Secondary to Mesalamine in a Patient With Inflammatory Bowel Disease. Cureus 2024; 16:e52587. [PMID: 38370999 PMCID: PMC10874644 DOI: 10.7759/cureus.52587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
Mesalamine is a first-line drug used in the treatment of inflammatory bowel disease (IBD), specifically ulcerative colitis (UC), with side effects ranging from gastrointestinal effects to cardiotoxicity. We present a rare case of mesalamine-induced myopericarditis in a patient with IBD, who presented with epigastric pain and was found to have elevated an c-reactive protein (CRP) in the absence of chest pain and any other gastrointestinal symptoms. This case highlights the importance of including myopericarditis as a differential for IBD patients on mesalamine with an isolated elevated CRP, especially within the first month of initiating this medication, as drug cessation usually leads to immediate clinical improvement.
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Affiliation(s)
- Nikhila Appala
- Internal Medicine, Kasturba Medical College, Manipal, IND
| | - Hima Veeramachaneni
- Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, USA
| | - Anshika Khare
- Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, USA
| | - Preeyanka Sundar
- Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, USA
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Andrei V, D'Ettore N, Scheggi V, di Mario C. Mesalazine-induced myopericarditis: a case series. Eur Heart J Case Rep 2023; 7:ytad424. [PMID: 37719002 PMCID: PMC10504860 DOI: 10.1093/ehjcr/ytad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/07/2023] [Accepted: 08/30/2023] [Indexed: 09/19/2023]
Abstract
Background Inflammatory bowel diseases (IBD) are characterized by chronic inflammation of the gastrointestinal tract but can have multiorgan involvement. Mesalazine (5-ASA) is a key therapeutic agent in IBD. Mesalazine has rare but potentially life-threatening side effects such as cardiac injury. Case summary We present two cases of myopericarditis, documented also with cardiac magnetic resonance, that we attributed to 5-ASA hypersensitivity: the first is a young woman with ulcerative colitis who developed myopericarditis after the initiation of 5-ASA, with a good clinical response after discontinuation; the second is a 79-year-old man who developed symptoms of heart failure after the diagnosis of IBD and the introduction of 5-ASA. Discussion Mesalazine may cause rare but potentially life-threatening cardiac injury, which can be difficult to distinguish from acute IBD-induced cardiac inflammation.
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Affiliation(s)
- Valentina Andrei
- Division of Structural Interventional Cardiology, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
- Department of Clinical & Experimental Medicine, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
| | - Nicoletta D'Ettore
- Division of Structural Interventional Cardiology, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
- Department of Clinical & Experimental Medicine, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
| | - Valentina Scheggi
- Department of Clinical & Experimental Medicine, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
- Division of Cardiovascular and Perioperative Medicine, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
| | - Carlo di Mario
- Division of Structural Interventional Cardiology, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
- Department of Clinical & Experimental Medicine, University Hospital Careggi, Largo Brambilla 3, 50133 Florence, Italy
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Xiao Y, Powell DW, Liu X, Li Q. Cardiovascular manifestations of inflammatory bowel diseases and the underlying pathogenic mechanisms. Am J Physiol Regul Integr Comp Physiol 2023; 325:R193-R211. [PMID: 37335014 PMCID: PMC10979804 DOI: 10.1152/ajpregu.00300.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
Inflammatory bowel disease (IBD), consisting of ulcerative colitis and Crohn's disease, mainly affects the gastrointestinal tract but is also known to have extraintestinal manifestations because of long-standing systemic inflammation. Several national cohort studies have found that IBD is an independent risk factor for the development of cardiovascular disorders. However, the molecular mechanisms by which IBD impairs the cardiovascular system are not fully understood. Although the gut-heart axis is attracting more attention in recent years, our knowledge of the organ-to-organ communication between the gut and the heart remains limited. In patients with IBD, upregulated inflammatory factors, altered microRNAs and lipid profiles, as well as dysbiotic gut microbiota, may induce adverse cardiac remodeling. In addition, patients with IBD have a three- to four times higher risk of developing thrombosis than people without IBD, and it is believed that the increased risk of thrombosis is largely due to increased procoagulant factors, platelet count/activity, and fibrinogen concentration, in addition to decreased anticoagulant factors. The predisposing factors for atherosclerosis are present in IBD and the possible mechanisms may involve oxidative stress system, overexpression of matrix metalloproteinases, and changes in vascular smooth muscle phenotype. This review focuses mainly on 1) the prevalence of cardiovascular diseases associated with IBD, 2) the potential pathogenic mechanisms of cardiovascular diseases in patients with IBD, and 3) adverse effects of IBD drugs on the cardiovascular system. Also, we introduce here a new paradigm for the gut-heart axis that includes exosomal microRNA and the gut microbiota as a cause for cardiac remodeling and fibrosis.
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Affiliation(s)
- Ying Xiao
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, United States
| | - Don W Powell
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, United States
| | - Xiaowei Liu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Qingjie Li
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, United States
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Chen J, Duan T, Fang W, Liu S, Wang C. Analysis of clinical characteristics of mesalazine-induced cardiotoxicity. Front Pharmacol 2022; 13:970597. [PMID: 36188558 PMCID: PMC9520406 DOI: 10.3389/fphar.2022.970597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Mesalazine is the first-line inflammatory bowel disease (IBD) treatment. However, it can cause fatal cardiotoxicity. We aimed to analyze the clinical characteristics of mesalazine-induced cardiotoxicity and provide evidence for clinical diagnosis, treatment, and prevention. Methods: We collected Chinese and English literature on mesalazine-induced cardiotoxicity from 1970 to 2021 for retrospective analysis. Results: A total of 52 patients (40 males and 12 females) were included, with a median age of 24.5 years (range 9–62) and a median onset time of 14 days (range 2–2880). Cardiotoxicity manifested as myocarditis, pericarditis, and cardiac pericarditis. The main clinical manifestations are chest pain (82.7%), fever (46.2%), and respiratory symptoms such as dyspnea and cough (40.4%). The levels of troponin T, creatine kinase, C-reactive protein, leukocyte count, erythrocyte sedimentation rate, and other biochemical markers were significantly increased. Cardiac imaging often suggests myocardial infarction, pericardial effusion, myocardial necrosis, and other symptoms of cardiac injury. It is essential to discontinue mesalamine immediately in patients with cardiotoxicity. Although corticosteroids are a standard treatment option, the benefits remain to be determined. Re-challenge of mesalamine should be carefully considered as cardiotoxic symptoms may reoccur. Conclusion: Mesalazine may cause cardiotoxicity in patients with inflammatory bowel disease, which should be comprehensively diagnosed based on clinical manifestations, biochemical indicators, and cardiac function imaging examinations. Mesalazine should be immediately discontinued, and corticosteroids may be an effective treatment for cardiotoxicity.
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Affiliation(s)
| | | | | | - Shikun Liu
- *Correspondence: Shikun Liu, ; Chunjiang Wang,
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Bauer M, Baholli L, Uflacker L, Rolffs S. [Perimyocarditis as a complication of a multiple drug therapy in the treatment of a severe ulcerative colitis episode]. Dtsch Med Wochenschr 2022; 147:1055-1060. [PMID: 35970187 DOI: 10.1055/a-1894-4615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
HISTORY AND CLINICAL FINDINGS A 19-year-old patient presented as an inpatient with an acute flare-up of ulcerative colitis for about six weeks and symptom progression for one and a half weeks. The patient was treated with topical and oral 5-aminosalicylic acid (5-ASA) preparations and oral prednisolone. With an intensification of the prednisolone dose, administration of a monoclonal antibody (Vedolizumab) and antibiotic therapy, inpatient discharge against medical advice. Oral administration of ciprofloxacin due to continued elevated infection parameters. The 5-ASA administration was continued. In the following two weeks, recurrent episodes of fever and renewed inpatient admission. INVESTIGATIONS AND DIAGNOSIS Microbiological detection of Acinetobacter ursingii in blood cultures. Echocardiographic evidence of pericardial effusion. Transesophageal echocardiography revealed no evidence of infective endocarditis. Serological evidence of elevated cardiac enzyme levels. An MRI scan of the heart confirmed the diagnosis of perimyocarditis. TREATMENT AND COURSE Intensive medical care and resistogram-based antibiotic therapy with meropenem, stopping the topical and oral 5-ASA doses and not continuing the integrin antagonist therapy. In addition, start of guideline-based cardiac insufficiency therapy and change of therapy to a tumor necrosis factor alpha blocker. Under the accelerated application scheme, stabilization and improvement of the general condition protracted. After two months of hospitalization, the patient was discharged to outpatient care. DISCUSSION Perimyocarditis may occur after long-term administration of 5-ASA. The integrin antagonist as a new therapy can also be a causal factor. Therapeutic management when the cause of the complaint is unclear depends on the symptoms and the most likely cause of the disease. If there is no response to therapy, carry out early re-evaluations.
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Affiliation(s)
- Marcus Bauer
- Medizinische Klinik II, St. Vincenz-Krankenhaus Datteln, Datteln, Germany
| | - Loant Baholli
- Medizinische Klinik II, St. Vincenz-Krankenhaus Datteln, Datteln, Germany
| | - Lutz Uflacker
- Medizinische Klinik I, St. Vincenz-Krankenhaus Datteln, Datteln, Germany
| | - Sven Rolffs
- Medizinische Klinik I, St. Vincenz-Krankenhaus Datteln, Datteln, Germany
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Piazza I, Burti C, Assolari A, Greco S, Benetti A, Cosentini R, Ferrero P. Acute myocarditis as first presentation of severe ulcerative colitis in a young man. Multidisciplinary management and long-term follow-up. J Cardiol Cases 2022; 26:46-50. [DOI: 10.1016/j.jccase.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/26/2022] [Accepted: 02/19/2022] [Indexed: 12/12/2022] Open
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