Two Birds With One Stone: The Decisive Role of Cardiac MRI in Identifying Both Hypertrophic Cardiomyopathy and Pericarditis Simultaneously in a Patient with Chest Pain

A 35-year-old Hispanic male presented at an outside facility with chest pain a few days after a long road trip. The initial electrocardiogram (EKG) showed sinus tachycardia with no other abnormality. His D-dimer was positive but a subsequent computed tomography angiography (CTA) of the chest was negative for pulmonary embolism. An echocardiogram showed trace pericardial effusion with a normal ejection fraction (EF) of 70% and severe asymmetric septal hypertrophy. Satisfactory Doppler signals to assess the gradient across the left ventricle outflow tract (LVOT) could not be obtained on echocardiogram. The patient was diagnosed with acute pericarditis, which was treated medically with an improvement of his symptoms. Later, he presented to our facility for an outpatient cardiac magnetic resonance (CMR) with and without contrast, which showed severe asymmetric septal hypertrophy measuring 29 mm with substantial patchy myocardial delayed enhancement and systolic anterior motion of the mitral leaflet with flow dephasing of LVOT. These findings were diagnostic of hypertrophic obstructive cardiomyopathy. CMR also showed signs consistent with pericarditis. A Holter monitor was unremarkable for arrhythmia. A stress echocardiogram did not demonstrate any drop in blood pressure during exercise. His interventricular septum measured 29 mm on cardiac magnetic resonance imaging (MRI), which was very close to the 30 mm cut-off for an implantable cardioverter-defibrillator (ICD). In addition, he had a marked delayed enhancement in the hypertrophied septum due to gadolinium uptake, which is also considered a high-risk feature for sudden cardiac death. After discussions between the patient, cardiologist, cardiac imaging specialist, and electrophysiologist, a subcutaneous ICD was pursued, which was successfully implanted. He was started on medical treatment. He was followed closely in the clinic and has remained asymptomatic for the past two years.