Discordant clinical presentation and pathophysiology: insights with cardiac magnetic resonance

We report serial cardiac magnetic resonance (CMR) imaging finding in a 23-year-old man admitted with wide complex ventricular tachycardia (VT), chest pain and syncope. Serial CMR was performed prior to and following clinical stabilization after treatment for suspected myocarditis. The initial CMR exam showed mildly thickened mid left ventricular septum with mild hyperintensity lesion on T2-weighted image (T2WI). There was enhancement in subepicardial mid inferoseptal wall and right ventricular insertion on late gadolinium enhancement (LGE) image. A subsequent CMR exam after resolution of symptoms and normalization of cardiac markers demonstrated diffuse mid and subepicardial edema of left ventricle on T2WI. Diffuse mid and subepicardial enhancement of left ventricle on LGE. The extent of LGE was increased compared to the initial CMR exam. The potential explanation for the discordance between clinical observations and imaging findings is discussed.