Unveiling Arrhythmogenic Cardiomyopathy Masquerading as Myocarditis in a Professional Athlete.

backgroundElite athletes undergoing cardiovascular screening may present with findings that necessitate further work-up based on consensus electrocardiographic criteria. These findings may reveal conditions that may affect their cardiovascular health and livelihood. CASE SUMMARY: We present the case of an asymptomatic elite American-style football player with lateral T-wave inversions, frequent premature ventricular contractions, mildly reduced ejection fraction, and progressive myocardial scarring on cardiac magnetic resonance imaging. Genetic testing revealed a pathogenic desmin (DES) variant associated with arrhythmogenic and dilated cardiomyopathy spectrum. DISCUSSION: After multidisciplinary evaluation and extensive shared decision-making, the athlete was initially withheld from play. Given the absence of a plakophilin-2 (PKP2) mutation, lack of sustained ventricular arrhythmias, and preserved functional capacity, and after extensive shared decision-making, the athlete returned to play with strict longitudinal surveillance. TAKE-HOME MESSAGE: This case highlights the complexity of integrating advanced imaging, genetics, and athlete values into return-to-play decisions, and the ethical challenges when medical uncertainty intersects with professional identity and livelihood.