A case of Japanese spotted fever complicated with acute myocarditis

Japanese spotted fever (JSF) is caused by Rickettsia japonica. Although it induces a variety of complications, acute myocarditis has never been reported as a complication of JSF. We treated a JSF patient who developed acute myocarditis. To our knowledge, this is the first case of JSF complicated with acute myocarditis.

Co-infection with two Chlamydophila species in a case of fulminant myocarditis*

OBJECTIVE

The aim of this study is to describe a case of fulminant myocarditis caused by co-infection with Chlamydophila pneumoniae and Chlamydophila psittaci in order to facilitate diagnosis and clinical management of patients suffering from this rare but life-threatening condition.

DESIGN

Case report.

SETTING

Intensive care unit of Innsbruck Medical University.

PATIENT

A 24-yr-old patient admitted with septicemia and cardiac failure.

INTERVENTIONS

Cardiopulmonary resuscitation, extracorporal membrane oxygenation, implantation of an extracorporal cardiac assist device, and antibiotic treatment with erythromycin.

MEASUREMENTS AND MAIN RESULTS

Cp. pneumoniae and Cp. psittaci were identified by means of polymerase chain reaction and electron microscopy in the patient's myocytes. Successful weaning off the ventricular assist device was performed within 2 wks after commencement of antibiotic therapy.

CONCLUSIONS

This case report demonstrates co-infection with Cp. pneumoniae and Cp. psittaci to be a hitherto unknown cause of fulminant myocarditis. There is a particular risk of misdiagnosis of viral myocarditis, which must be avoided. Patients should be transferred to a center where extracorporal membrane oxygenation therapy and molecular diagnosis of all members of the family Chlamydiaceae are available.

Reducing susceptibility to bacteremia after experimental burn injury: a role for selective decontamination of the digestive tract

We proposed that selective decontamination of the digestive tract (SDD) initiated after experimental burn injury would decrease myocardial inflammation and dysfunction after a second insult such as septic challenge. Rats were divided into eight experimental groups. Groups included sham burn plus sham sepsis, burn alone, sepsis alone, and burn plus sepsis given either water by oral gavage for 5 days after burn (or sham burn) or given oral antibiotics (polymyxin E, 15 mg; tobramycin, 6 mg; 5-flucytosin, 100 mg given by oral gavage, 2x daily for 5 days after burn or sham burn). Cardiac function and inflammation were studied 24 h after septic challenge. In the absence of SDD, burn alone, sepsis alone, or burn plus septic challenge promoted cardiac myocyte secretion of TNF-alpha (burn, 174+/-11; sepsis, 269+/-19; burn+sepsis, 453+/-14 pg/ml), IL-1beta (burn, 35+/-2; sepsis, 29+/-1; burn+sepsis, 48+/-7 pg/ml), and IL-6 (burn, 143+/-18; sepsis, 116+/-3; burn+sepsis, 248+/-12 pg/ml) compared with values measured in sham (TNF-alpha, 3+/-1; IL-1beta, 1+/-0.4; IL-6, 6+/-1.5 pg/ml) (P<0.05). Impaired ventricular contraction and relaxation responses were evident in the absence of SDD [burn+sepsis: left ventricular pressure (LVP), 65+/-4 mmHg; rate of LVP rise (+dP/dt), 1,320+/-131 mmHg/s compared with values measured in sham: LVP, 96+/-4 mmHg; +dP/dt, 2,095+/-99 mmHg/s, P<0.05]. SDD treatment of experimental burn attenuated septic challenge-related inflammatory responses and improved myocardial contractile responses, producing cardiac TNF-alpha, IL-1beta, and IL-6 levels, LVP, +dP/dt, and rate of LVP fall (-dP/dt) values that were significantly better (P<0.05) than values measured in burn plus sepsis in the absence of SDD. This work confirms that endogenous gut organisms contribute to sensitivity to subsequent infectious challenge.

Take traveller's diarrhoea to heart

Diarrhoea is a common health problem among travellers worldwide. We focus attention on the recognition of the postinfectious complications of traveller's diarrhoea. An English traveller, aged 43, attended a hospital in Benidorm (Spain) complaining of chest pain. A week previously, fever and severe diarrhoea were present. The electrocardiogram and cardiac enzymes were not normal. The coproculture yielded Campylobacter jejunii. Acute myocarditis can be an exceptional complication of gastroenteritis masquerading as acute myocardial infarction or leading to congestive heart failure.

Recruitment of macrophages and polymorphonuclear leukocytes in Lyme carditis

Lyme arthritis, caused by the spirochete Borrelia burgdorferi, can be recurrent or prolonged, whereas Lyme carditis is mostly nonrecurring. A prominent difference between arthritis and carditis is the differential representation of phagocytes in these lesions: polymorphonuclear leukocytes (PMN) are more prevalent in the joint, and macrophages predominate in the heart lesion. We have previously shown differential efficiency of B. burgdorferi clearance by PMN and macrophages, and we now investigate whether these functional differences at the cellular level may contribute to the observed differences in organ-specific pathogenesis. When we infected mice lacking the neutrophil chemokine receptor (CXCR2(-/-) mice) with spirochetes, we detected fewer PMN in joints and less-severe arthritis. Here we have investigated the effects of the absence of the macrophage chemokine receptor CCR2 on the development and resolution of Lyme carditis in resistant (C57BL/6J [B6]) and sensitive (C3H/HeJ [C3H]) strains of mice. In B6 CCR2(-/-) mice, although inflammation in hearts is mild, we detected an increased burden of B. burgdorferi compared to that in wild-type (WT) mice, suggesting reduced clearance in the absence of macrophages. In contrast, C3H CCR2(-/-) mice have severe inflammation but a decreased B. burgdorferi burden compared to that in WT C3H mice both at peak disease and during resolution. Histopathologic examination of infected hearts revealed that infected C3H CCR2(-/-) animals have an increased presence of PMN, suggesting compensatory mechanisms of B. burgdorferi clearance in the hearts of infected C3H CCR2(-/-) mice. The more efficient clearance of B. burgdorferi from hearts by CCR2(-/-) versus WT C3H mice suggests a natural defect in the recruitment or function of macrophages in C3H mice, which may contribute to the sensitivity of this strain to B. burgdorferi infection.

Myopericarditis in a patient with Campylobacter enteritis: a case report and literature review

Myocarditis sometimes occurs as a complication of bacterial infection, including enteric infections caused by Salmonella, Shigella and Yersinia. Only a few cases of Campylobacter-associated myocarditis are known. We describe a 47-y-old patient with myopericarditis in association with Campylobacter spp. enteritis, and review similar cases previously described in the English literature.

Myocardial Involvement in Rocky Mountain Spotted Fever: A Case Report and Review

Rocky Mountain Spotted Fever (RMSF), caused by Rickettia rickettsii, is a serious tickborne illness that is endemic in the southeastern United States. Although it is most commonly known as a cause of fever and rash, it can have systemic manifestations. The myocardium may rarely be involved, with symptoms that can mimic those of acute coronary syndromes. This report describes a case of serologically proven RMSF causing symptomatic myocarditis, manifested by chest pain, elevated cardiac enzyme levels, and decrease myocardial function. After treatment with antibiotics, the myocarditis resolved. Thus, although unusual, the clinician should be aware of myocardial disease in patients with appropriate exposure histories or other clinical signs of RMSF. Close monitoring and an aggressive approach are essential to reduce mortality rates.

Rheumatic fever-mimicking carditis as a first presentation of chronic active Epstein-Barr virus infection

A 7-y-old girl presented with prolonged fever, arrhythmia and cardiomegaly during the treatment course of group A beta-haemolytic streptococcal pharyngitis. The isolated rheumatogenic strain M1 suggested the diagnosis of rheumatic fever. However, serous pericardial effusion contained high levels of Epstein-Barr virus (EBV) DNA. Clonally proliferating EBV+ T cells were determined in the circulation. The atypical carditis without valvitis was then complicated by coronary artery dilatations. Four months after the start of prednisolone plus antiviral/bacterial therapy, EBV+ T-cell lymphoma developed in the thigh.

CONCLUSION

Atypical carditis may be a notable and life-threatening presentation of chronic active EBV infection to be differentiated from rheumatic fever.

Lyme carditis: complete atrioventricular dissociation with need for temporary pacing

Lyme borreliosis is a tick-borne disease. Cardiac manifestations of the disease are extremely rare. We report a case of Lyme carditis in an otherwise healthy male, who presented to the Accident & Emergency Department with chest pain, dizziness and generally symptoms indicating ischaemic heart disease. This patient, without documented history of Lyme disease, acutely developed third-degree atrioventricular block, which required placement of a transvenous pacemaker and resolved when the patient was administered doxycycline.

Antibody-mediated disease remission in the mouse model of lyme borreliosis

In the mouse model of Lyme borreliosis, the host immune response during infection with Borrelia burgdorferi results in the remission of carditis and arthritis, as well as global reduction of spirochete numbers in tissues, without elimination of infection. These events were recapitulated by passive transfer of immune serum from infected immunocompetent mice or T-cell-deficient mice to severe combined immunodeficient (SCID) mice. Previous studies have shown that immune serum is reactive against arthritis-related protein (Arp) and that Arp antiserum induces arthritis remission. However, although immune serum from T-cell-deficient mice induced disease remission, it was not reactive against Arp, suggesting that antibody to another antigen may be responsible. T-cell-deficient mouse immune serum was reactive to decorin binding protein A (DbpA). Therefore, DbpA antiserum was tested to determine its ability to induce disease remission in SCID mice. Antisera to Arp or DbpA induced both carditis and arthritis remission but did not significantly reduce spirochete numbers in tissues, based upon quantitative flaB DNA analysis, nor did treatment affect RNA levels of several genes, including arp and dbpA. Immunohistochemical labeling of spirochetes in hearts and joints during disease remission induced by adoptive transfer of lymphocytes, passive transfer of immune serum, or passive transfer of DbpA antiserum revealed that such treatment resulted in elimination of spirochetes from heart base and synovium but not vascular walls, tendons, or ligaments. These results suggest that Arp and DbpA antibodies may be active as disease-resolving components in immune serum but antibody against other antigens may be involved in reductions of spirochetes in tissues.

Stat1 deficiency exacerbates carditis but not arthritis during experimental lyme borreliosis

Activation of the transcription factor Stat1 by interferon-gamma (IFN-gamma) is an important step in the development of antimicrobial effector mechanisms against many bacterial pathogens. Susceptibility to murine Lyme arthritis has been correlated with the production of several proinflammatory cytokines, especially IFN-gamma. To determine the role of IFN-mediated effector mechanisms in the development of Lyme borreliosis, we infected Stat1-deficient mice on both resistant (DBA), and susceptible (C3H) genetic backgrounds. Arthritis in Stat1(/) mice was similar to that of wild-type controls in both mouse strains. Spirochete loads in tissues were also unchanged in Stat1(/) mice. C3H Stat1(/) mice exhibited increased inflammation in the heart, whereas carditis was unchanged in DBA Stat1(/) mice. These results demonstrate that inhibition of macrophage activation and responses to IFN-gamma-mediated signaling do not alter the arthritis resistance or susceptibility phenotype; however, they do affect the severity of carditis in susceptible mouse strains.

Fatal myocardial necrosis caused by Staphylococcus lugdunensis and cytomegalovirus in a patient with scleroderma

A 42-year-old woman developed a rapidly progressing fatal heart failure. At the autopsy extensive necrosis of the myocardium was seen, with an almost complete absence of inflammatory cells and the presence of bacterial structures identified as Staphylococcus lugdunensis by PCR. In addition, the cytomegalovirus genome was found to be located inside the cardiomyocytes.

Fatal group A streptococcal myopericarditis during influenza A infection

Influenza A infection can be a serious and life-threatening disease in young children. Even in those who die, however, the cause of death may not be obvious. In this illustrative report, a 7-year-old child with acute influenza A infection developed an unsuspected fatal secondary infection caused by group A streptococcus. The diagnosis of bacterial myopericarditis was made at autopsy.

Prognostic significance of electrocardiographic abnormalities in diphtheritic myocarditis after hospital discharge: a long-term follow-up study

OBJECTIVE

We aimed to investigate the long-term cardiac mortality and the relationship between cardiac mortality and electrocardiographic abnormalities in patients with diphtheritic myocarditis who survived after hospital discharge.

MATERIALS AND METHODS

Between 1991 and 1996, 32 patients (all males, mean age 21.00 +/- 3.77 years) surviving diphtheritic myocarditis were included in the study and they were followed up for an average of 16.3 months (range 10.3-26.8 months) after hospital discharge. Clinical evaluation, ECG, and echocardiography were performed on admission, daily while in hospital and at the time of discharge. ECG changes were permanent during the follow-up period. The causes of death of the patients during follow-up period were inferred from the death records of the patients and talking to the people witnessing cardiac arrest.

RESULTS

We observed that the patients with left bundle branch block (LBBB) and T wave inversion at hospital discharge had lower survival rates than that of the patients without these ECG changes in the long term. Although univariate Cox regression analysis identified LBBB (P = 0.001) and T wave inversion (P = 0.014) as the predictors of survival, only LBBB was an independent predictor of survival in multivariate Cox regression analysis. Adjusted hazard ratio was calculated as 13.67 for LBBB (P = 0.001; CI = 2.81-66.28).

CONCLUSION

Diphtheritic myocarditis does not only demonstrate a malignant clinical course during acute phase of the disease, but also during the long-term follow-up period, especially in patients with LBBB and T wave inversion. Besides, T wave inversion and LBBB can help us to predict survival rate of the patients in long term. Moreover, LBBB is an independent predictor of long-term survival in diphtheritic myocarditis.

MyD88 deficiency results in tissue-specific changes in cytokine induction and inflammation in interleukin-18-independent mice infected with Borrelia burgdorferi

Toll-like receptors (TLRs) play an important role in the control of infection with Borrelia burgdorferi. Deficiencies in TLR-2 or the shared TLR adapter molecule MyD88 have been shown to result in greatly increased bacterial burdens in mice. However, although in vitro studies have shown that the activation of TLR pathways by B. burgdorferi results in the release of inflammatory cytokines, studies in deficient mice have shown either no change or increased rather than decreased inflammation in infected animals. In this study, we looked at mechanisms to explain the increase in inflammation in the absence of MyD88. We found that MyD88-deficient mice infected with B. burgdorferi did not show increased inflammation at sites typically associated with Lyme disease (joints and heart). However, there was markedly increased inflammation in the muscles, kidneys, pancreas, and lungs of deficient animals. Muscle inflammation was typically seen perivascularly and perineuronally similar to that seen in infected humans. Chemotactic chemokines and cytokines were greatly increased in the muscle and kidneys of MyD88-deficient animals but not in the joints or heart tissue, suggesting that MyD88-independent pathways for recognizing B. burgdorferi and inducing these chemokines are present in the muscle and kidneys. Interleukin-18 signaling through MyD88 does not appear to play a role in either control of infection or inflammation.

[Mycoplasma pneumoniae myopericarditis in children]

Mycoplasma pneumoniae myocarditis is a rare condition, potentially very serious and seldom described in children. It is classically attributed to direct invasion or to an indirect immunological mechanism. The authors report the case of a 10 year old boy with myopericarditis, proved by authentic seroconversion, complicating congenital mitro-aortic valvular disease. In this case, the spectacular response to steroid therapy was in favour of an indirect immunological causal mechanism of the left ventricular dysfunction and pericardial involvement.

Sudden Death from Tubercular Myocarditis

Tuberculous myocarditis is a rare finding. We present the case of a 33-year-old woman who was in good health and who died suddenly at home. Autopsy and histopathologic examinations revealed granulamatous lesions in the myocardium, lungs, lymph nodes, liver, and spleen. No fast acid bacilli were demonstrated on histological examination. The presence of a Mycobacterium tuberculosis DNA complex was identified using a polymerase chain reaction (PCR) on formalin-fixed paraffin-embedded histological samples. An HIV test carried out on the blood obtained during the autopsy was negative according to the DNA amplification technique (PCR) and enzyme-linked immunosorbent assay serological test. We hypothesize that the mechanism of death was severe ventricular arrhythmia due to granulomatous proliferation in the structures of the interventricular septum.

[Cardiogenic shock due to acute myocarditis complicating leptospirosis]

A 48 year old man was admitted to the intensive care unit with septicaemic shock associated with febrile jaundice and anuric renal failure. Within hours, he developed cardiogenic shock with multi-organ failure due to an acute myocarditis refractory to catecholamines and requiring intra-aortic balloon pumping. The diagnosis was an ictero-haemorrhagic leptospirosis, the outcome of which was finally favourable. Myocarditis is an underestimated complication of leptospirosis because it is often symptomless. The main signs are arrhythmias, conduction defects and ST-T wave abnormalities which have little clinical expression. The disease may progress and is sometimes fatal. Leptospirosis myocarditis should therefore be carefully considered because of its potential severity and its reversibility with appropriate antibiotic therapy and also the necessity of initial management in a specific infrastructure.

[Ictero-haemorrhagic leptospirosis with a cardiac presentation in a patient returning from an endemic zone]

On returning from a tropical area, the occurrence of rapidly evolving cardiogenic shock in an infectious context should quickly suggest the diagnosis, for which specific treatment can affect the outcome. The dramatic case of a young female presenting with ictero-haemorrhagic leptospirosis diagnosed post-mortem, demonstrated this pathology with the unusual association of complete atrio-ventricular block and myocarditis in a haemorrhagic context.

[Impact of chronic Chlamydia pneumoniae infection on left ventricular remodeling after myocardial infarction]

BACKGROUND

Postmyocardial infarction left ventricular remodeling is modified by inflammatory processes and structural changes in the myocardium. Chlamydia pneumoniae (Chp) causes chronic myocyte infection, affects apoptosis and TNF-alpha production, and may induce cross reactivity with alpha myosin. This is the way in which this intracellular pathogen may modulate remodeling on the cellular and organ level.

MATERIAL AND METHODS

The study was conducted in 101 patients with a first myocardial infarction in whom we evaluated the serological features of Chp infection using the ELISA method and echocardiographic left ventricular volume at 10 days and 10 weeks after the infarction.

RESULTS

Patients with chronic Chp infection had a tendency toward higher end-diastolic volume at 10 weeks after the infarction (123 +/- 32.9 ml vs. 134 +/- 34.7 ml, p = 0.09). In order to better define this relationship we used ROC analysis and measured levels of antibodies: IgG = 117 EIU and IgA = 15.6 EIU by which we divided the patients into two subgroups. Those with IgG > or = 117 EIU and IgA > or = 15.6 EIU belong to the subgroup with chronic and active Chp infection. These patients had larger left ventricular end-diastolic volumes (155.8 vs. 123.1 ml, p = 0.0005) and end-systolic volumes (77.4 vs. 59.5 ml, p = 0.006) at 10 weeks after the infarction. Both subgroups were similar with respect to age, gender, history of arterial hypertension, systolic and diastolic blood pressure values, infarct site, reperfusion, infarct size, left ventricular ejection fraction and left ventricular contractility index. Type of reperfusion therapy and pharmacological treatment at 10 days and at 10 weeks did not differ, either.

CONCLUSIONS

Chronic Chlamydia pneumonie infection modifies the course of left ventricular remodeling.

Three cases of cardiac complications associated with Campylobacter jejuni infection and review of the literature

Presented here are three cases of acute cardiac disease (myocarditis, myopericarditis, and acute atrial fibrillation) associated with Campylobacter jejuni infection, followed by a review of the corresponding literature. Since Campylobacter jejuni is the most common cause of human bacterial enteritis in developed countries, these cases emphasize the importance of keeping cardiac complications in mind when treating patients with acute gastroenteritis due to this pathogen.