Sudden cardiac death due to giant cell inflammatory processes.J Forensic Sci. 2007 Jul;52(4):943-8. Epub 2007 May 25.

Granulomatous inflammation of the myocardium may occur in a number of systemic disease processes including those with infectious etiologies such as fungal, mycobacterial and parasitic infections, as well as hypersensitivity reactions, and rarely autoimmune disorders. In many of these disorders, giant cells are components of the inflammatory infiltrate. Systemic granulomatous processes of unknown pathogenesis, most notably sarcoidosis, may also be associated with involvement of the myocardium. Occasionally, these disorders are associated with sudden death due to pathologic involvement of the heart. In contrast, giant cell myocarditis, also known as idiopathic myocarditis, a rare, frequently fulminant and fatal disorder of unknown etiology, is isolated to the heart and lacks systemic involvement. This disorder is most commonly diagnosed at autopsy. We present two cases in which sudden death resulted from a giant cell inflammatory process affecting the myocardium. Both individuals lacked antemortem diagnoses and collapsed at their respective places of employment. These cases compare and contrast the clinical and pathologic issues involved in the differential diagnoses of the subgroup of sudden cardiac deaths resulting from giant cell inflammatory processes that affect the myocardium, as well as the value of histologic examination and immunohistochemical studies.

Acute heart failure due to fulminant and giant cell myocarditis.Herz. 2006 Nov;31(8):767-70.

Acute or fulminant nonischemic, dilated cardiomyopathy (DCM) is an uncommon cause for heart failure with a highly variable prognosis that is in part dependent on histopathology and in part on clinical presentation. Once common causes of acute DCM are excluded using standard clinical tests, the specific inflammatory and infectious causes of DCM should be systematically evaluated and treated. Specific histopathologic forms include fulminant lymphocytic myocarditis, which has an excellent prognosis with standard heart failure care. By contrast, giant cell myocarditis, which may be fulminant or acute, has a poor prognosis and frequently requires heart transplantation or immunosuppression for long-term survival. Noninvasive tests that may support the diagnosis of fulminant or acute myocarditis include cardiac magnetic resonance imaging and biomarkers of cardiac injury. Certain clinical, hemodynamic, and echocardiographic variables predict risk of death or transplant in acute myocarditis. This article will compare the presentation, prognosis, and treatment options for several uncommon causes for acute heart failure and suggest certain clinical scenarios in which the likelihood of specific histopathologic disorders is high enough to warrant endomyocardial biopsy if noninvasive tests are inconclusive.