Clozapine and myocarditis: a case series from the New Zealand Intensive Medicines Monitoring Programme

AIM

To examine a New Zealand case series of clozapine-associated myocarditis.

METHODS

All cases of myocarditis in the Intensive Medicines Monitoring Programme's (IMMP) clozapine database were identified and reviewed.

RESULTS

25 cases of myocarditis associated with the use of clozapine have been reported to the IMMP. The majority of cases (84%) were male and the mean age was 35.5 years. Myocarditis occurred at daily clozapine doses ranging from 12.5 mg to 500 mg. Eighty percent of the cases developed within 1 month of starting the medicine, although in three cases the onset was more than a year after commencing clozapine. Of the 25 cases, 2 patients died.

CONCLUSIONS

This New Zealand case series of clozapine-associated myocarditis is similar to a recent Australian case series. Clozapine-associated myocarditis most often occurs within 1-2 months of starting clozapine, but it may develop at any time while on the medicine, and can occur even at very low doses. A data-linkage study using national morbidity and mortality datasets could estimate the incidence of clozapine-associated myocarditis in New Zealand.

A myocarditis outbreak with fatal cases associated with adenovirus subgenera C among children from Havana City in 2005

BACKGROUND

Among multiple causes of acute myocarditis, viral infection, especially that due to enteroviruses and adenoviruses, is the leading cause. In the summer 2005 an outbreak of a febrile syndrome accompanied by acute cardiac decompensation occurred in infants and young children in Havana City. Eleven patients had a rapid evolution of disease and there were 8 fatalities from cardiac failure secondary to myocarditis.

OBJECTIVE

The aim of the present study was to determine the etiological agent responsible for this outbreak.

STUDY DESIGN

Children admitted to the pediatric hospitals of Havana City from July 3 to August 2 with this clinical presentation were studied. Forty samples of necropsy tissue, cerebrospinal fluid, stools and serum were tested by molecular methods for 14 respiratory viruses, 6 herpesviruses and generic enteroviruses and flavirus and alfaviruses. Viral isolation was performed in A-549 cells. Isolated viruses were typed by sequence analysis.

RESULTS

Adenovirus genome was detected in 6 of the 8 fatal cases-the lungs in 5 (63%) and the myocardium in 3 (37%). In two fatal cases, viral genome was detected in both lung and myocardium. Adenovirus was isolated in five fatal cases. In all three non-fatal cases, adenovirus genome was detected and adenovirus was isolated into two. Sequence analysis showed that adenovirus type 5 was the only isolate from fatal cases and adenovirus 1 the only isolate in non-fatal cases. No other viruses were found by PCR or isolation techniques.

CONCLUSION

Adenovirus was the etiologic agent implicated in this myocarditis outbreak and adenovirus type 5 was associated with fatal outcome.

Rickettsial infections and their clinical presentations in the Western Province of Sri Lanka: a hospital-based study

BACKGROUND

Rickettsial infections are re-emerging. A study of the geographical distribution of rickettsial infections, their clinical manifestations, and their complications would facilitate early diagnosis.

METHODS

Thirty-one selected patients from the Western Province of Sri Lanka were studied for rickettsial species, clinical manifestations, and complications.

RESULTS

Of 31 patients with possible rickettsioses, 29 (94%) fell into the categories of confirmed, presumptive, or exposed cases of acute rickettsial infections (scrub typhus was diagnosed in 19 (66%), spotted fever group in eight (28%)). Early acute infection or past exposure was suggested in two (7%) cases; cross-reactivity of antigens or past exposure to one or more species was suggested in nine (31%). Seventeen out of 19 (89%) patients with scrub typhus had eschars. Nine out of 29 (32%) patients had a discrete erythematous papular rash: seven caused by spotted fever group, two by scrub typhus. Severe complications were pneumonitis in eight (28%), myocarditis in five (17%), deafness in four (14%), and tinnitus in two (7%). The mean duration of illness before onset of complications was 12.0 (SD 1.4) days. All patients except one made a good clinical recovery with doxycycline or a combination of doxycycline and chloramphenicol.

CONCLUSIONS

In a region representing the low country wet zone of Sri Lanka, the main rickettsial agent seems to be Orientia tsutsugamushi. Delay in diagnosis may result in complications. All species responded well to current treatment.

[Clinical implications of renal affection among systemic manifestations of infectious endocarditis]

AIM

To assess the importance of renal affection and other systemic manifestations of infectious endocarditis (IE) among factors of unfavourable IE prognosis.

MATERIAL AND METHODS

The examination including bacteriological blood test, transthoracic echocardiography was made in 54 patients with IE (35 males and 19 females aged 17-75 years). Transesophageal echocardiography and coagulogram examination were additionally performed in 11 and 45 patients, respectively.

RESULTS

Modern methods of statistic processing were employed to study systemic IE manifestations. Among them, prognostically significant were singled out and analysed including renal affection. Clinical variants of renal affection were determined in IE patients and their characteristics were determined: high incidence and severity of erythrocyturia, rare occurrence of arterial hypertension, frequent episodes of acute renal failure. A close correlation is shown between IE-associated renal affection, DIC symptoms and thrombocytopenia. Signs of renal damage in IE patients raise probability of other systemic manifestations including prognostically significant ones. This allows one to consider renal affection as a marker of an unfavourable IE course.

CONCLUSION

A complex of significant factors of IE unfavorable outcome is determined including such systemic manifestations as severe renal affection, thromboembolism, splenomegaly. These factors are of importance in deciding on surgical intervention--valve replacement.

Is the incidence of perimyocarditis increased following Campylobacter jejuni infection?

Preliminary case reports have suggested an association between Campylobacter jejuni infection and occurrence of perimyocarditis. In the present study we analysed the incidence of perimyocarditis requiring hospitalization in a Danish cohort of 6,204 patients with Campylobacter-positive stool cultures and compared it to the incidence in a matched control cohort comprising 62,040 subjects. We found no cases of pericarditis in the Campylobacter population and an incidence rate of 3.2 [95% confidence interval (CI): 0.8-12.9] per 100,000 person-years in the control population. The incidence rate of myocarditis was 16.1 (95% CI: 2.3-114.4) per 100,000 person-years in the Campylobacter population compared to 1.6 (95% CI: 0.2-11.4) per 100,000 person-years in the control cohort. We found no statistically significant difference in perimyocarditis between the two groups.

[Morphologic features of sudden cardiac death in Yunnan province, with emphasis on myocarditis]

OBJECTIVES

To study the pathologic feature of sudden cardiac death in Yunnan province and to investigate the role of myocarditis.

METHODS

During the period from 1991 to 2006, there were 29 cases of sudden cardiac death with autopsy performed. Fourteen of these cases were diagnosed to have myocarditis based on Dallas criteria and World Heart Federation's consensus. The clinical and pathologic findings were reviewed. The cardiac conduction system was examined in details by serial sectioning in 3 cases.

RESULTS

Fourteen cases suffered with myocarditis, which accounted for 48% of all cases of sudden cardiac death studied. The age of the deceased ranged from 8 to 68 years (mean = 30 years), with male-to-female ratio equaled to 9:5. Lymphocytic myocarditis and neutrophil myocarditis were the two major types, affecting 11 and 3 cases, respectively. The inflammatory infiltrates were often patchy rather than diffuse. The inflammatory foci were detected only in 8% to 42% (average = 20%) of the paraffin sections of the heart tissue. These lesions were usually located in the lateral wall of left ventricle and occasionally in interventricular septum and right ventricular wall. Myocardial injury was mild in most cases while patchy myocytolysis or coagulation necrosis was observed only in a few cases. Most of the lesions were relatively new and histologic evidence of myocardial repairing sometimes coexisted. Pericarditis and subacute endocarditis were also identified in 4 and 1 cases, respectively. Atrioventricular node was involved by myocarditis in 1 of the 3 cases examined for cardiac conduction system. Two cases showed gross evidence of cardiac dilatation (either left ventricle or biventricular). Respiratory tract and pulmonary infection was present in 5 cases.

CONCLUSIONS

Myocarditis represents one of the major pathologic changes of sudden cardiac death occurring in Yunnan province. The inflammation is usually focal. Further studies are required for delineation of possible etiologies which may include virus, bacteria or exogenous toxin.

Pulmonary and cardiac infections in athletes

Pulmonary and cardiac infections in the athlete can have a wide range of presentations and complications. These infections may present few problems for the training athlete or become life threatening. The team physician must be able to make an accurate diagnosis, give the appropriate treatment, understand the potential complications, and ensure proper follow-up and return-to-play protocols.

Subclinical carditis in rheumatic fever: A systematic review

OBJECTIVE

Subclinical carditis (SCC)--pathological valvular regurgitation detected on echocardiography that is not evident clinically--has been reported in acute rheumatic fever (ARF), but its significance is unknown. We aimed to review the existing literature on the prevalence and outcome of SCC in ARF.

METHODS

We conducted a systematic literature review using MEDLINE.

RESULTS

Prevalences of SCC in ARF ranged from 0% (in one study only) to 53% in 23 articles. The weighted pooled prevalence of SCC in ARF was 16.8% (95%CI 11.9 to 21.6). This increased slightly to 18.1% (95%CI 11.1 to 25.2) by analysing only the 10 studies that applied full World Health Organization criteria for SCC diagnosis. The weighted pooled prevalence of persistence or deterioration of SCC 3 to 23 months after ARF diagnosis was 44.7% (95%CI 19.3 to 70.2) from 11 articles.

CONCLUSION

SCC is relatively common in ARF. Although some studies suggest that SCC lesions may persist or deteriorate, the available data are insufficient and of poor quality, so no confident conclusions can be drawn about the prognosis of SCC. Until better studies are conducted, clinicians will have to make management decisions that are not evidence-based. These decisions will have important practical implications for the use of echocardiography acutely and during follow-up, diagnosis of ARF, and duration of secondary prophylaxis in patients with SCC.

Laser Lead Extraction in Adult Congenital Heart Disease

BACKGROUND

In adults with congenital heart disease (ACHD), lead extraction procedures are expected to parallel increasing transvenous pacemaker and defibrillator implantations. We sought to assess the safety and feasibility of laser lead extraction in ACHD.

METHODS AND RESULTS

All laser lead extractions (Spectranectics, Colorado Springs, CO, USA) performed at the Montreal Heart Institute between September 2000 and August 2005 were prospectively registered. Efficacy and complications in patients with ACHD were compared to the larger cohort. Laser lead extraction was attempted on 270 leads in 175 patients. In ACHD, 23 (five atrial, 15 ventricular pacing, and three defibrillator) leads were targeted in 16 patients. Indications were: infection 44%, dysfunction 25%, upgrade 25%, and pain 6%. Patients with ACHD were younger (43.0 +/- 13.5 vs 63.7 +/- 14.7 years, P < 0.0001) and had a higher proportion of active fixation leads (74% vs 37%, P = 0.0013). Lead age in patients with and without ACHD was 9.0 +/- 5.2 vs 7.7 +/- 5.2 years (P = 0.2713). Overall, 21 of 23 leads (91%) were successfully extracted in ACHD compared with 220 of 247 leads (89%) (P = 0.7405). One major complication (6.3%) occurred in ACHD (tricuspid valve laceration) compared with five major (3.0%) and eight minor (5.0%) complications in patients without ACHD. Presence of ACHD did not modulate procedural success (OR 1.3, 95% CI [0.3, 5.8]) or complications (OR 1.0, 95% CI [0.2, 4.4]). Median procedural time was 27 minutes longer in ACHD (127 vs 100 minutes, P = 0.0595).

CONCLUSION

In selected patients with ACHD, laser lead extraction may be performed with a safety and efficacy profile comparable to patients without ACHD.

Death Caused by Myocarditis in Wayne County, Michigan

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.

Presentation, Patterns of Myocardial Damage, and Clinical Course of Viral Myocarditis

BACKGROUND

Enteroviruses and adenoviruses have been considered the most common causes of viral myocarditis, but parvovirus B19 (PVB19) and human herpesvirus 6 (HHV6) are increasingly found in endomyocardial biopsy samples.

METHODS AND RESULTS

Consequently, our aim was to evaluate the prevalence and clinical presentation of cardiac PVB19 and/or HHV6 infection in a cohort of myocarditis patients and to follow its clinical course. In addition, we sought to demonstrate patterns of myocardial damage and to determine predictors for chronic heart failure. Our study design consisted of a cardiovascular magnetic resonance protocol as well as endomyocardial biopsies in the myocardial region affected as indicated by cardiovascular magnetic resonance. One hundred twenty-eight patients were enrolled by clinical criteria. In the group of myocarditis patients (n=87), PVB19 (n=49), HHV6 (n=16), and combined PVB19/HHV6 infections (n=15) were detected most frequently. The remaining patients were diagnosed with healing myocarditis (n=15) or did not have myocarditis (n=26). Patients with PVB19 presented in a manner similar to that of myocardial infarction; most had typical subepicardial late gadolinium enhancement in the lateral wall and recovered within months. Conversely, patients with HHV6 and especially with HHV6/PVB19 myocarditis presented with new onset of heart failure, had septal late gadolinium enhancement, and frequently progressed toward chronic heart failure.

CONCLUSIONS

Our data indicate that PVB19 and HHV6 are the most important causes for viral myocarditis in Germany and that the clinical presentation is related to the type of virus. Furthermore, clinical presentation, type of virus, and pattern of myocardial damage are related to the clinical course.

Predictive factors of a fulminant course in acute myocarditis

BACKGROUND

Patients who develop fulminant myocarditis often die of sudden cardiac arrest, arrhythmia, or severe heart failure soon after onset if they do not receive percutaneous cardiopulmonary support in time. The purpose of this study was to identify the risk factors of clinical symptoms/signs or laboratory findings that could predict the fulminant course of acute myocarditis.

METHODS AND RESULTS

Thirty-five patients (mean age 28 +/- 8 years, 17 males) who had been admitted to intensive care unit with the diagnosis of acute myocarditis by clinical presentations were retrospectively recruited. They were divided into the fulminant group (n = 11) and the non-fulminant group (n = 24). Clinical features, laboratory data, and images on admission were analyzed. Overall in-hospital mortality was 17% (6/35). Mortality was higher in the fulminant group (45% vs. 4%, p = 0.027). Multivariate analysis revealed that prolongations of the QRS complex (118 +/- 27 vs. 88 +/- 10 ms, p = 0.048) and depressed left ventricular ejection fraction (41 +/- 7% vs. 57 +/- 7%, p = 0.027) were the only independent factors significantly associated with the fulminant course of acute myocarditis.

CONCLUSION

The in-hospital mortality of acute fulminant myocarditis was high. Prolongations of the QRS complex and depressed left ventricular ejection fraction on admission were independent positive predictors for the development of acute fulminant myocarditis.

Myocarditis and heart failure associated with hepatitis C virus infection

BACKGROUND

The aim of study is to determine the prevalence of hepatitis C virus (HCV) infection and myocardial injury among patients enrolled in the Myocarditis Treatment Trial. HCV infection has recently been noted in patients with cardiomyopathies and myocarditis. However, prevalence of HCV infection in myocarditis and heart failure remains to be clarified.

METHODS AND RESULTS

Patients with heart failure up to 2 years in duration without a distinct cause were enrolled in the trial between 1986 and 1990. Frozen blood samples were available from 1355 among 2233 patients enrolled and examined for presence of anti-HCV antibodies, circulating cardiac troponins I and T, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Anti-HCV antibodies were identified in 59 of 1355 patients (4.4%). This higher prevalence of HCV infection than that observed in the general US population (1.8%), varied widely (0-15%) among the different medical centers and regions. The concentrations of circulating cardiac troponin (cTn) I were elevated in 17 of 56 patients (30%), and cTnT was detectable in 28 of 59 patients (48%) with HCV antibodies, suggesting the persistence of ongoing myocardial injury. The concentrations of NT-proBNP were elevated in 42 of 42 patients (100%) with HCV antibodies, (10,000 +/- 5860 pg/mL), a mean value significantly greater than in 1276 patients without HCV antibody (2508 +/- 160 pg/mL, P < .0001).

CONCLUSION

Anti-HCV antibodies were identifiable in sera stored for 13 to 17 years and were more prevalent in patients with myocarditis and HF than in the general population. In regions where its prevalence is high, HCV infection may be an important cause of myocarditis and HF. NT-proBNP is a more sensitive marker of myocardial injury than cardiac troponins in patients with heart failure from HCV myocarditis.

Review of 609 patients with rheumatic fever in terms of revised and updated Jones criteria

BACKGROUND

To investigate the findings and prognosis of rheumatic fever (RF) patients seen in the past 20 years and to compare the last two decades.

METHODS

The medical records of all RF patients admitted to Gazi University Department of Pediatric Cardiology during 1982-2002 were reviewed. The decade from 1.1.1982 to 31.12.1991 was designated as 1980s and the following decade as the 1990s.

RESULTS

Among the 609 RF cases, there was no difference between the two decades regarding mean age, male/female ratio, most of the minor manifestations and findings of the preceding streptococcal infection. As the rate of carditis declined in 1990s, rates of arthritis and chorea increased. Severity of carditis and admissions with reactivation decreased during 1990s. The two decades did not differ regarding mean age, gender ratio, pericarditis rate, number and type of valvular involvement and sequel of carditis cases. Severity of carditis and number of valvular involvement influenced the first-year prognosis. Almost one-third of the arthritis cases had monoarthritis in both decades. Atypical cases with small-joint involvement were detected number of which increased during the 1990s.

CONCLUSIONS

The two decades do not seem to differ regarding most of the manifestations of RF. More emphasis should be given to atypical cases such as small-joint involvement and monoarthritis and silent carditis.

Diabetes and myocarditis in voles and lemmings at cyclic peak densities--induced by Ljungan virus?

Although it is well-documented from theoretical studies that pathogens have the capacity to generate cycles, the occurrence and role of pathogens and disease have been poorly empirically studied in cyclic voles and lemmings. In screening for the occurrence of disease in cyclic vole and lemming populations, we found that a high proportion of live-trapped Clethrionomys glareolus, C. rufocanus, Microtus agrestis and Lemmus lemmus at high collective peak density, shortly before the decline, suffered from diabetes or myocarditis in northern Scandinavia. A high frequency of animals had abnormal blood glucose (BG) levels at the time of trapping (5-33%). In contrast, C. rufocanus individuals tested at a much lower overall density, and at an earlier stage relative to the decline in the following cycle, showed normal BG concentrations. However, a high proportion (43%) of a sample of these individuals kept in captivity developed clinical diabetes within five weeks, as determined by BG levels and a glucose tolerance test performed at that later time. A new picornavirus isolated from the rodents, Ljungan virus (LV), was assumed to cause the diseases, as LV-induced diabetes and myocarditis, as well as encephalitis and fetal deaths, were observed in laboratory mice. We hypothesize that LV infection significantly affects morbidity and mortality rates in the wild, either directly or indirectly, by predisposing the rodents to predation, and is at least involved in causing the regular, rapid population declines of these cyclic voles and lemmings. Increased stress at peak densities is thought to be an important trigger for the development of disease, as the occurrence of disease in laboratory mice has been found to be triggered by introducing stress to LV-infected animals.

Longitudinal study of a natural outbreak of heart and skeletal muscle inflammation in Atlantic salmon, Salmo salar L

Heart and skeletal muscle inflammation (HSMI) is a transmissible disease of farmed Atlantic salmon, Salmo salar L. It is characterized by significant epi-, endo- and myocarditis, as well as myositis, particularly involving red skeletal muscle. The aetiology of HSMI is currently unresolved, though a viral cause is suspected. Since its discovery in 1999, HSMI has become an increasing problem for the Norwegian farming industry, with some farms experiencing yearly outbreaks and subsequent economic losses. In the present study an Atlantic salmon farm was studied from December 2003 to April 2005. Samples from apparently healthy as well as clinically diseased fish were collected monthly and examined histopathologically. The first fish to be diagnosed with HSMI was sampled in May, 8 months after transfer to sea. A clinical outbreak of HSMI followed in June, when all fish in the sample had lesions consistent with HSMI. Subsequent samples revealed that cardiac lesions decreased in severity 2 months after the start of the outbreak, but that multiple foci of cellular infiltration and necrosis persisted throughout the year. There appeared to be a shift in lesion location from being most severe in the compact myocardium in early stages of disease to a greater involvement of the atrium and spongy layer of the ventricle in later samples. Late samples also showed increased fibrosis of cardiac tissue. In conclusion, HSMI appears to be a severe disease with elevated mortality, morbidity close to 100% and prolonged duration.

Myocarditis Outbreak among Adults, Illinois, 2003

An outbreak of myocarditis occurred among adults in Illinois in 2003. Diagnostic testing of myocardial tissues from 3 patients and comprehensive tests for enterovirus and adenovirus of other specimens from patients were inconclusive. Appropriate specimen collection from patients with idiopathic cardiomyopathy and further enhancement of diagnostic techniques are needed.

The role of echocardiography in diagnosing carditis in the setting of acute rheumatic fever

OBJECTIVES

Acute rheumatic fever and its sequel, rheumatic heart disease, is a major problem in children, adolescents and young adults. Despite the widespread application of the Jones criterions, carditis is either underdiagnosed or overdiagnosed. Echocardiography is rarely used optimally for precise diagnosis. The objective of our study, therefore, was to define the potential role of echocardiography in detecting carditis in the setting of acute rheumatic fever.

MATERIALS AND METHODS

We performed echocardiography in 452 consecutive patients with acute rheumatic fever, clinically diagnosed by the strict Jones criterions, using the patients as part of a multi-centric and double blinded prospective study.

RESULTS

Of our 452 patients, 230 were males, and 222 were females. The youngest was aged 1 year 11 months, while the oldest was a 51-year-old female. Out of the 452 cases of acute rheumatic fever, 239 patients (52.8%) had arthritis. Out of 164 cases of clinically diagnosed carditis, only 141 cases had echocardiographic evidence of carditis (85.97%). The remaining 23 patients (14%) had functional murmurs, tachycardia, or anaemia. Of the patients, 2 also had congenitally malformed hearts. Of 40 patients with rheumatic chorea, 28 (70%) had echocardiographic evidence of carditis or valvitis. Polyarthralgia was seen in 213 cases (47.12%), from which only 38 patients (17.8%) had carditis clinically, albeit that 88 patients (41.3%) showed echocardiographic evidence of subclinical carditis or valvitis.

CONCLUSION

Echocardiography, when carried out in patients with acute rheumatic fever diagnosed strictly according to the Jones criterion, can avoid both overdiagnosis and underdiagnosis of carditis. A high incidence of carditis, or subclinical carditis, is detected by echocardiography when performed in patients with rheumatic chorea or arthralgia.

Real or media-mediated outbreak of coxsackie infections in 2002 in Greece?

The purpose of this study was to provide evidence about the existence of a coxsackie B outbreak in Greece in 2002 by comparing data of laboratory confirmed coxsackie B recent infections in northern Greece between 1998-2001 with data from 2002. The infections were confirmed serologically, using the indirect immunofluorescence method detecting IgM antibodies for coxsackie B1-B6 viruses. Sera from 2701 patients residents of northern Greece who were suspected to be suffering from coxsackie B virus infections were examined: 2056 between 1998 and 2001, and 645 in 2002. The comparison between the results of laboratory confirmed cases and data available at the laboratory between the two periods showed that: The total number of patients examined per year was higher in 2002 (645 versus an annual average of 514 in 1998-2001). The proportion of laboratory confirmed recent infections was lower in 2002 (27.8% versus 32.7%) and the estimated incidence was 0.66/10,000 for 2002 and 0.32-0.84/10,000 for 1998-2001. The age distribution differed: the proportions of cases in children versus cases in adults were reversed in 2002 compared with 1998-2001, with a higher proportion among children in 2002. The difference between the two periods was statistically significant. Children aged 3-5 years were the age group most affected in 2002. Seasonal distribution remained the same for both periods (peaks in spring and autumn). In 2002, three fatal cases occurred in April, but no deaths were reported in 1998-2001. The clinical syndromes involved also differed: cases of respiratory infections, mainly pneumonia, rose from 5.75% to 24.3% in children in 2002 and cases of myopericarditis rose in adults from 13% in 1998-2001 to 29.5% in 2002. The last finding, combined with the involvement of the media (because of the three fatal cases) and the panic in the general public that followed suggested that an outbreak had occurred, but we conclude that there was no outbreak.

Myocarditis, pericarditis and cardiomyopathy in patients treated with clozapine

Clozapine is known to cause cardiac side-effects, including myocarditis, pericarditis and cardiomyopathy. Prompted by a case of clozapine-related pericarditis in our hospital we undertook a review of the literature for reports of myocarditis, pericarditis and cardiomyopathy occurring in patients treated with clozapine. This is the first comprehensive review of the literature on this topic.