Correct!
5. All of the above
The patient has subacute myocarditis. Chagas disease, caused by the parasite Trypanosoma cruzi is endemic to Latin and South America and is a common cause of myocarditis. However, Chagas disease is characterized by a chronic dilated cardiomyopathy. An acute presentation as seen in our patient, is distinctly rare with T cruzi. which can be diagnosed by a blood smear but usually requires antibody confirmation. In the US, viral myocarditis is more common and coxsackie, adeno and parvo viruses being common causes. However, her work up for any infectious cause was negative.
She rapidly improved clinically with further treatment with furosemide and carvedilol. Losartan was started but discontinued because her blood pressure was typically in the 90/60 mmHg range. An MRI of her heart was consistent with myocarditis, with an EF of 55%. Endomyocardial biopsy was considered unnecessary due to her rapid improvement. Discharge was planned with an ambulatory event monitor, since no episode of arrhythmia had been observed to explain the periodic “spells” that occurred before her sudden episode of deterioration.
However, just prior to discharge, a clinician recalled the patient’s husband’s report of a blood pressure of 198/? mmHg during her episode of deterioration and questioned the diagnosis of pheochromocytoma.
Based on the clinical presentation, which measurements are indicated next? (Click on the correct answer to proceed to the fourth and final panel)