A 42-year-old male patient with a history of fulminant macrophage-dominated myocarditis, who was treated by immunosuppressive therapy for two months, was admitted to our university hospital due to the incidental diagnosis of a myocardial abscess of the left ventricle. The myocardial lesion was suspected by routine cardiac magnetic resonance imaging (CMR).

CMR revealed the myocardial abscess of the infero-basal wall of the LV and a cystic lesion as septic focus in the right upper lobe of the lung. A computed tomography (CT) scan confirmed these findings. TOE depicted the suspicious myocardial lesion of the LV, which could not be seen in TTE. We performed positron emission tomography–computed tomography (PET-CT) for further clarification. Multiple metabolically active areas were found in the lungs, heart, in the muscular and subcutaneous tissue, and in the colon. Most interestingly, PET-CT illustrated again the large myocardial abscess within the LV wall. Finally, microbiological examination yielded evidence of Aspergillus fumigatus and Candida glabrata. The invasive candidiasis/aspergillosis was treated with voriconazole and caspofungin for five weeks.

Here, we report a rare case of a suspected fungal myocardial abscess. The diagnosis of myocardial abscesses is an extraordinary challenge as the clinical relevance can range from asymptomatic courses to myocardial wall rupture and septic shock. TTE and TOE are helpful primary diagnostic tools but are not sufficient to discriminate the origin of suspicious lesions. CT and CMR are valuable modalities with several advantages. CT scans identify typical abscess characteristics comprising fluid density and contrast-enhancing myocardial wall thickening as we could show. CMR has a superior spatial and temporal resolution, so its sensitivity and specificity to correctly diagnose myocardial abscesses is significantly higher than other imaging tools. CMR detects intramyocardial lesions independent from their origin. PET/CT scans supported our findings in CMR/CT, as we aimed to differentiate between a myocardial abscess from lesions of other origin.

Repeated PET-CT scans during follow up proved that all metabolically active septic foci had resolved under the antimycotic therapy.