Hypersensitivity myocarditis associated with ephedra use

Background: Ephedrine has previously been described as a causative factor o f vasculitis but myocarditis has not yet been associated with either ephedr ine or its plant derivative ephedra. Case Report: A 39-year-old African Ame rican male with hypertension presented to Rush Presbyterian St. Luke's Medi cal Center with a 1-month history of progressive dyspnea on exertion, ortho pnea, and dependent edema. He was taking Ma Huang (Herbalife) 1-3 tablets t wice daily for 3 months along with other vitamin supplements, pravastatin, and furosemide. Physical examination revealed a male in mild respiratory di stress. The lung fields had rales at both bases without audible wheezes. In ternal jugular venous pulsations were 5 cm above the sternal notch. Medical therapy with intravenous furosemide and oral enalapril was initiated upon admission. Cardiac catheterization with coronary angiography revealed norma l coronary arteries, a dilated left ventricle, moderate pulmonary hypertens ion, and a pulmonary capillary wedge pressure of 34 mm Hg. The patient had right ventricular biopsy performed demonstrating mild myocyte hypertrophy a nd an infiltrate consisting predominantly of lymphocytes with eosinophils p resent in significantly increased numbers. Treatment for myocarditis was in itiated with azothioprine 200 mg daily and prednisone 60 mg per day with a tapering course over 6 months. Anticoagulation with warfarin and diuretics was initiated and angiotensin-converting enzyme inhibition was continued. H ydralazine was added later. One month into therapy, an echocardiogram demon strated improved left ventricular function with only mild global hypokinesi s. A repeat right ventricular biopsy 2 months after the first admission sho wed no evidence of myocarditis. At 6 months, left ventricular ejection frac tion was normal (EFN 50%) and the patient asymptomatic. Conclusion: Ephedra (Ma Huang) is the suspected cause of hypersensitivity myocarditis in this patient due to the temporal course of disease and its propensity to induce vasculitis.