Introduction: The objective of this paper is to highli-ght the importance to distinguish the three entities: Acute Coronary Syndrome (ACS)/ Takotusubo Car-diomyopathy/Myocarditis based on signs, symptoms, paraclinical exploration and the particularity of the optimal therapeutic course. The term ACS is used for any suddenly triggered condition characterized by a decrease in blood flow to the myocardium. Takotsubo cardiomyopathy also known as stress-induced cardi-omyopathy or apical ballooning of the left ventricle is a reversible acquired pathology, characterized by acu-te systolic dysfunction. Myocarditis is an inflammato-ry disease of the myocardium, this condition remains a challenge in terms of diagnosis as it is manifested through various clinical pictures. Clinical presentation of the patients together with paraclinical investigations help distinguish between these three entitis.

Methods: In this paper we discuss an atypical case of cardiovascular disease in a young patient with risk fac-tors, who was admitted in the emergency department for epigastric sharp pain, lasting a few minutes, witho-ut radiation, accompanied by nausea and physical as-thenia. Onset of symptoms started 2-3 hours prior to being admitted in the emergency department withing Craiova 1^st County Emergency Hospital. Initially, based on clinical presentation, acute ECG changes and eleva-ted biomarkers, it was diagnosed as ACS and treated accordingly adapted to ESC guidelines. On further re-evaluation of the patient with advanced imaging tech-niques such as MRI the diagnosis of myocarditis was stabilished and appropriate treatment was initiated.

Results: Myocarditis is highly polymorphic, depending on the etiological type, the extent and location of the le-sions, the age of the patient and possible associated car-diac pathology. In our case, the patient had a favorable evolution despite significant ECG changes, impressive dynamics of myocardial necrosis markers and clinical presentation. Coronarography revealed a stenosis of 20% in segment II of LAD, which is why we continu-ed further investigations. Among other test numerous laboratory tests have been performed on viral / bacte-rial etiology of myocarditis, but the only change was in coagulation factor VIII. Cardiac MRI was performed, which revealed: Contrast enhancement at the level of anterior interventricular septum, anterior wall and all other segments, diffuse, imprecisely delimited, compri-sing the entire thickness of the myocardial wall.

Conclusions: MRI changes suggestive of acute myo-carditis. Myocarditis is the consequence of a wide range of myocardial lesions it represents a challenging diagno-sis, mainly because there is no pathognomonic clinical presentation, and the disease may masquerade as a va-riety of non-inflammatory myocardial diseases which could cause confusion in diagnosis and that could be fatal for the patient. Cardiac MRI used as a diagnostic test in suspected myocarditis, increasing the sensitivity and specificity of this pathology. Myocarditis remains a challenge in terms of diagnosis, because it is mani-fested by various clinical pictures. In order to establish the diagnosis of myocarditis, high degree of suspicion as well as optimal investigations are required for promt detection and appropriate treatment.