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Rationale:  Myocarditis is a rare but potentially fatal complication of Still's disease (about 7% of total cases).    Patient concerns:  A 42-year-old woman was admitted to our ward with high-grade fever, rash and polyarthralgia, lasting since 4 weeks and rapidly complicated by MAS and acute heart failure.    Diagnoses:  Adult Onset Still's Disease rapidly developping macrophage activation syndrome and disseminated intravascular coagulopathy, further complicated by iperacute myocarditis with cardiac arrest.    Interventions:  After failure of conventional therapies (steroids plus cyclosporine and then biological therapy with Anakinra 100 mg/day), the patient was treated with anakinra 100 mg sc 1 fl 4 times a day.    Outcomes:  Fast clinical and laboratoristic improvement and subsequent disease remission with complete recovery of cardiac function.    Lessons:  This is the first case report in which high doses of Anakinra have been used to treat a refractory AOSD complicated by MAS and myocarditis. In AOSD complicated by life-threatening conditions, probably we need to consider aggressive therapeutic approaches with higher doses of Il-1 receptor blocker to switch off the hyper-inflammation.

Refractory adult-onset Still disease complicated by macrophage activation syndrome and acute myocarditis