question: Background Myocardial involvement, especially with ventricular tachycardia as an initial presentation, is uncommon in scleroderma Case A 56 year-old male presented with exertional dyspnea, palpitations and bilateral hand arthralgias Physical examination showed regular tachycardia, no jugular venous distension, clear lungs, no cardiac murmurs and skin thickening of digits of both hands Electrocardiogram showed sinus tachycardia CXR showed bibasilar interstitial prominence Laboratory studies showed troponin 0 15 ng/mL, normal BNP, WBC 2 27 K/uL and negative SARS-CoV2 PCR 24 hours after admission, he developed sustained monomorphic ventricular tachycardia and hypotension, responding to amiodarone, lidocaine and IV fluids Cardiac catheterization showed no CAD CT chest showed no pulmonary embolism but lower lobe reticular, ground-glass opacities Echocardiogram revealed moderate LV systolic dysfunction and inferolateral hypokinesis Cardiac MRI showed similar wall motion abnormalities and diffuse sub-epicardial myocardial scar Decision-making The patient was arrhythmia free on sotalol and carvedilol Transbronchial lung biopsy was negative for sarcoidosis Corticosteroids were started empirically A defibrillator was placed for secondary prevention Rheumatoid factor was negative, anti-CCP weakly positive (25 u), ANA &gt;1:320, ACE levels normal, ESR 69 mm/h, CRP 15 2 He was diagnosed with scleroderma and started on Cellcept Three months after hospitalization, he is free of ventricular arrhythmias and arthralgias are improved Conclusion Cardiac involvement in autoimmune disease can lead to rhythm abnormalities and sudden cardiac death (1);it is often missed in scleroderma and if found, diagnosis is usually made more than one year after rheumatologic diagnosis (2) Autoimmune myocarditis (AM) is associated with poor prognosis (3) Early initiation of anti-arrhythmic agents, medical optimization for LV dysfunction, ICD placement and corticosteroids/immunosuppressants have benefited our patient Early recognition of AM and multidisciplinary approach are imperative for successful outcome