title: Successive immunosuppressive treatment of fulminant myocarditis that is refractory to mechanical circulatory support.
abstract: BACKGROUND
  Long-term prognosis in patients with fulminant myocarditis can be favorable; however, for 32-36% of patients, this condition becomes fatal during the acute stages despite the use of mechanical circulatory support. Other therapeutic options may be needed for patients in whom these conditions are resistant to aggressive management.
  
  
  METHODS
  We present a case of fulminant myocarditis that rapidly progressed to cardiogenic shock and in-hospital cardiac arrest in a 46-year-old male. The patient promptly received inotropic agents, intra-aortic balloon pump therapy, and extracorporeal membrane oxygenation. However, creatinine kinase (CK), C-reactive protein (CRP), and QRS width increased significantly between days 1 and 3 of treatment; the patient's hemodynamic profile deteriorated despite this treatment regimen. Intravenous methylprednisolone was initiated on day 3 at a dose of 1,000 mg/day and maintained for an additional three days. Less than 24 h after methylprednisolone administration, the QRS width decreased significantly from 0.44 s to 0.18 s. In addition, CK and CRP levels declined sharply, which is associated with hemodynamic improvement.
  
  
  CONCLUSIONS
  High doses of intravenous methylprednisolone may be considered a therapeutic option for patients with fulminant myocarditis that is refractory to usual management practices.
authors.affiliation: Department of Cardiology, Nagasaki Citizens Hospital, Nagasaki, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Nakashima
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Umeyama
authors.forename: Kazutoshi
authors.initials: K
authors.lastname: Minami
keywords: extracorporeal membrane oxygenation; fulminant myocarditis; immunosuppression