Fatal Asymptomatic Myocardial Infarction Following Stroke in a Fontan Adolescent: A Case of Occult Blastomycosis Infection.

Myocardial infarction from coronary ischemia in pediatric patients with Fontan circulation is a rare diagnosis with scarce data reported on it. We describe a case of a teenage male who initially presented with an acute occlusive right middle cerebral artery (MCA) stroke with a history of nonadherence to aspirin. He underwent a thrombectomy shortly after presentation and was not restarted on anticoagulation due to hemorrhagic transformation of the stroke postprocedure. He had no residual neurologic deficits. On the sixth day of his admission and without prior symptoms, he had a sudden cardiac arrest with pulseless electrical activity (PEA). After 80 min of resuscitation, including an unsuccessful attempt to cannulate for extracorporeal membrane oxygenation (ECMO), he was pronounced dead. On autopsy, he was noted to have an acute premortem right coronary artery (RCA) occlusion and blastomycosis infection of the lung. Patients with Fontan circulation are known to have a higher risk for thrombotic events, especially when not on any antiplatelet therapies, as well as immunologic derangements. This case suggests that an indolent infection in the setting of passive blood flow within the Fontan circulation may have contributed to a prothrombotic state which may have ultimately led to the stroke and myocardial infarction.