A 24-year-old previously healthy man develops rapidly progressive heart failure over two weeks, unresponsive to diuretics and inotropes, punctuated by recurrent ventricular tachycardia. Endomyocardial biopsy shows extensive lymphocytic infiltrate with prominent multinucleated giant cells and widespread myocyte necrosis without granulomas. What is the most appropriate next step in management beyond standard heart failure therapy?
- A High-dose intravenous immunoglobulin alone with outpatient follow-up
- B Immunosuppression with cyclosporine and corticosteroids, with early evaluation for transplantation ✓
- C Permanent pacemaker implantation and anticoagulation only
- D Observation, since spontaneous recovery occurs in the majority of cases
Explanation
Giant cell myocarditis is a fulminant autoimmune myocarditis of young adults marked by rapid hemodynamic deterioration, refractory ventricular arrhythmias, and near-uniform death within months if untreated. Biopsy shows multinucleated giant cells without well-formed noncaseating granulomas, which separates it from cardiac sarcoidosis. Treatment combines immunosuppression (cyclosporine with corticosteroids) with early transplant assessment, as many patients ultimately require transplantation. Spontaneous recovery, typical of some lymphocytic viral myocarditis, does not occur here.
Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.