Correct!
2. The thoracic CT shows interval improvement of the previously noted peripheral lung opacities
The previously noted peripheral and subpleural opacities have significantly improved. No new nodules are present. However, the pericardial effusion persists, and new smooth interlobular septal thickening is present, associated with new right-greater-than-left pleural effusions, and the myocardium shows an abnormal enhancement pattern. Furthermore, a small filling defect is seen within the apex of the left ventricle.
The patient was subsequently hospitalized and laboratory data showed the development of proteinuria, for which kidney biopsy was performed, showing acute tubular necrosis, but no glomerulonephritis. Echocardiography showed reduced left ventricular systolic function, left ventricular enlargement, and confirmed the present of left ventricular apical thrombus. Cardiac MRI (Figure 6) was performed and confirmed the presence of myocarditis as the cause of new left ventricular dysfunction and also demonstrated the left ventricular apical thrombus.
Figure 6. Cardiac MRI examination show left ventricular apical thrombus (arrow) within a dilated left ventricular cavity, and spotty areas of mid-wall delayed myocardial enhancement (arrowheads), the latter consistent with a non-ischemic cause of cardiomyopathy, particularly myocarditis. Left ventricular wall thickness is normal, arguing against hypertrophic cardiomyopathy and restrictive cardiomyopathy.
Serologic testing for cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA) / proteinase-3 specificity was negative, but perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) / myeloperoxidase specificity testing was positive, and her serum IgE was elevated.
Given the foregoing information, which of the following represents the most likely diagnosis for this patient? (Click on the correct answer to proceed to the seventh and final page)