Incidental Intramyocardial Bridging in a Myocarditis Patient Presenting With Focal ST Segment Depressions

Myopericarditis is an entity known to present with typical symptoms of viral prodrome and diffuse ST elevation (STE) and/or PR depressions on electrocardiogram (EKG). Atypical presentations of myocarditis such as focal STE have been cited in the literature, reflecting true coronary ischemia. However, myocarditis or pericarditis presenting with focal ST depressions is rarely seen. Myocarditis is usually overlooked as a differential for ST depressions seen on EKGs; hence, the case we present in this report highlights the importance of nonischemic causes presenting as ischemic changes on EKG. This case is unique as we have postulated a possible explanation for this finding. This report discusses the case of a young patient with myopericarditis presenting with focal ST depressions. This patient was also incidentally found to have intramyocardial bridging, usually a benign finding, on cardiac catheterization (which is shown in the case report). Our hypothesis is that the inflammation due to myocarditis in this patient led to inflammation of intramyocardial vessels, presenting as ST depressions. Since intramyocardial bridging is a common anomaly, we propose the question as to whether this could be a risk factor for sudden cardiac death and if it depends on the characteristic of the intramyocardial vessel. We would like to emphasize on the atypical presentations of this usual condition, a possible explanation for this finding, and the need for further testing for risk stratification in patients with this anomaly.