CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 96 AFRICA a right heart catheter revealed a high pulmonary capillary wedge pressure at 28 mmHg. Diastolic congestive heart failure with acute pulmonary oedema was diagnosed based on these findings, which was suspected to result from diffuse myocardial calcification. The patient was excluded from the heart transplantation waiting list given his age and uraemic state. Furthermore, he refused any invasive surgical procedures and declared ‘do not resuscitate’. The patient underwent bilateral pleurocentesis to relieve the symptoms. We prescribed inotropes to preserve cardiac function, beta-blockers and amiodarone to control the rhythm, and warfarin to prevent thromboembolism. Albumin supplements were also administered to reduce pulmonary oedema. Eventually, the pulmonary oedema faded, and the inotropes were tapered off under stable haemodynamic status. He was released from our hospital and attended regular out-patient follow-up visits. Discussion The aetiologies of myocardial calcification are categorised into dystrophic, metastatic and idiopathic calcification. With underlying end-stage renal disease, patients frequently exhibit calcium deposits throughout the body as metastatic calcification.3 Metastatic myocardial calcification is a frequent cause of heart failure in patients undergoing haemodialysis,4,5 which may cause wall motion abnormalities. Infection-related myocardial calcification, both bacterial and viral, has been reported to occur within a severe systemic infection or a myocarditis episode. The bacterial pathogens Pseudomonas spp. and Klebsiella pneumoniae are not uncommon in a septic episode, and hypoperfusion resulting from septic shock may cause the sequela of myocardial calcification.6 Epstein–Barr virus was reported to cause rhabdomyolysis and myocarditis in a clinical case report,7 resulting in dystrophic calcification of the myocardium. We also detected possible related infectious pathogens, but no positive results were confirmed. Myocarditis was excluded given the normal serum levels of creatine kinase (41 U/l) and troponin I (51 pg/ml). Diffuse massive myocardial calcification can also cause restrictive cardiomyopathy.8 In 1984, Silver et al.9 described the first case of massive endocardial calcification of the left ventricle. They reported that exertional dyspnoea and substernal chest pain were the initial symptoms. The symptoms were exacerbated by calcific deposits in the left ventricle, which became severe Fig. 1. Chest X-ray at the emergency roomrevealed pulmonary congestion and bilateral pleural effusion. Calcification of the aortic knob (white arrow) and mitral annulus (black arrow) was noted. Fig. 2. (A) The transverse computed tomography scan revealed diffuse circular calcification of the left side of the heart, from the mitral annulus (white arrow) and ventricular septum (black arrow), to the posterior left ventricle (white dotted arrow), which restricted the left ventricle in an eggshell. (B) The coronal computed tomography scan revealed diffuse calcification of the ventricular septum and mitral annulus (white arrow). A B
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