Rare cause of tachy- and bradycardias

A 53-year-old female patient from the Philippines was admitted with intermi ttent complete heart block and assumed coronary artery disease. Physical ex amination was normal except for moist pulmonary sounds. ECG and monitoring showed bifascicular block and poly morphic ventricular tachycardia. A marke dly reduced left ventricular function was seen in the echocardiogram. Coron ary angiography showed two vessel disease. Endomyocardial biopsy revealed f lorid giant cell myocarditis. Heart failure and ventricular arrhythmias wer e ameliorated under immunosuppressive triple-therapy (corticosteroid, cyclo sporin A, and azathioprine). Four weeks later, the patient received a cardi ac transplant without complications. Two months later, a clinically inappar ent cardiac rejection was diagnosed by endomyocardial biopsy, which was tre ated by corticoid pulse therapy and antithymocyteglobulin. Four weeks later , pneumocystis carinii pneumonia and cytomegaly virus exacerbation were dia gnosed and successfully treated. Idiopathic giant cell myocarditis is a rare disease with progressive conges tive heart failure and ventricular arrhythmias or complete heart block ofte n accompanied by syncope or sudden death. Associations with autoimmune dise ases have been reported. Giant cell myocarditis is diagnosed by endomyocard ial biopsy or at autopsy. Treatment is difficult and comprises immunosuppre ssive agents (triple-therapy) and cardiac transplantation. Recurrence of gi ant cell myocarditis in cardiac transplants has been described. Without imm unosuppressive treatment the median survival is three months.