A 22-year-old man develops acute chest pain, fever, and dyspnea 2 weeks after a flu-like illness. Troponin I is elevated at 8.2 ng/mL. ECG shows diffuse ST elevation. Coronary angiography reveals normal epicardial arteries. Cardiac MRI shows mid-wall late gadolinium enhancement in a non-coronary distribution. What is the most likely diagnosis?
- A Acute viral myocarditis ✓
- B Takotsubo stress cardiomyopathy
- C Acute pericarditis without myocardial involvement
- D Acute myocardial infarction with spontaneous recanalization
Correct answer: A. Acute viral myocarditis
Explanation
Myocarditis classically presents days to weeks after a viral prodrome with chest pain, elevated troponin, and ECG changes mimicking MI. Normal coronaries on angiography rule out obstructive CAD. Mid-wall or epicardial late gadolinium enhancement in a non-coronary distribution on CMR is the hallmark of myocarditis (Lake Louise criteria). Takotsubo shows apical ballooning with transmural edema, not diffuse ST elevation with normal coronaries in a young man.
Reference: Braunwald's Heart Disease, 12th ed.
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