CLINICAL HISTORY
A 35-year-old woman complained of progressively worsening chest pressure, dyspnea on exertion, and fatigue. Physical exam demonstrated signs of congestive heart failure. Medical management for heart failure was optimized. However, 11 months after her initial presentation, she underwent orthotopic heart transplantation for recalcitrant heart failure and symptomatic ventricular arrhythmias.
The patient's past medical history was significant for a fine needle aspiration biopsy of a parotid gland mass which revealed non-caseating granulomatous inflammation (performed one year prior to development of heart failure). The mass resolved without further treatment.
The patient had no other known medical problems. She denied tobacco, alcohol, and illicit drug use.
There was no known family history of heart disease.
LABORATORY DATA
Noncontributory
ANCILLARY STUDIES
Pre-transplant chest x-ray (Figure 1, left) with marked cardiomegaly. Lung parenchyma and mediastinum are unremarkable.
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Post-transplant chest x-ray (Figure 1, right) with normal heart size. Lung parenchyma and mediastinum remain within normal limits. |
| Figure 1: |
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Cardiac catheterization revealed normal coronary arteries and severely hypokinetic left ventricle (estimated ejection fraction 10-15%).
GROSS PATHOLOGY
Explanted heart (289gm) (Figure 2) with:
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- Left and right ventricular enlargement
- Marked epicardial thickening
- Extensive myocardial fibrosis with focal wall thinning
- Endocardial fibrosis and thickening
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| Figure 2: |
MICROSCOPIC PATHOLOGY
- Extensive myocardial fibrosis with chronic inflammation (Figure 3).
- Focal sheets of multinucleated giant cells, some containing asteroid bodies (Figure 4).
- Rare noncaseating granulomata (Figure 5).
- No organisms seen on AFB and GMS stains.
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