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Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med 2020; 31:163-169. [PMID: 33383171 PMCID: PMC7965406 DOI: 10.1016/j.tcm.2020.12.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/03/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.
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Affiliation(s)
- Shereif H Rezkalla
- Department of Cardiology & Cardiovascular Research, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449 USA; Adjunct Professor, University of Wisconsin, School of Medicine USA.
| | - Robert A Kloner
- Chief Science Officer, Scientific Director of Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, CA USA; Professor of Medicine (Clinical Scholar), Cardiovascular Division, Dept. of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA USA.
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Maisch B, Ruppert V, Pankuweit S. Management of fulminant myocarditis: a diagnosis in search of its etiology but with therapeutic options. Curr Heart Fail Rep 2015; 11:166-77. [PMID: 24723087 DOI: 10.1007/s11897-014-0196-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fulminant myocarditis is a clinical syndrome with signs of acute heart failure, cardiogenic shock, or life-threating rhythm disturbances in the context of suspected myocarditis. It is not an etiological diagnosis, but may have different underlying causes and pathogenetic processes - viral, bacterial, toxic, and autoreactive. Clinical management of the disease entity at the acute stage involves hemodynamic monitoring in an intensive care unit or similar setting. Rapid routine work-up is mandatory with serial EKGs, echocardiography, cardiac MRI, heart catheterization with endomyocardial biopsy for histology, immunohistology, and molecular analysis for the underlying infection and pathogenesis. Heart failure therapy is warranted in all cases according to current guidelines. For fulminant autoreactive myocarditis, immunosuppressive treatment is beneficial; for viral myocarditis, IVIg can resolve the inflammation, reduce the viral load, and even eradicate the microbial agent. ECMO, IABP, ventricular assist devices, LifeVest, or ICD implantation can bridge to recovery or to heart transplantation.
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Affiliation(s)
- Bernhard Maisch
- Medical Faculty of Philipps University Marburg and Cardiovascular Center Marburg, Erlenring 19, 35037, Marburg, Germany,
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Omura S, Kawai E, Sato F, Martinez NE, Chaitanya GV, Rollyson PA, Cvek U, Trutschl M, Alexander JS, Tsunoda I. Bioinformatics multivariate analysis determined a set of phase-specific biomarker candidates in a novel mouse model for viral myocarditis. CIRCULATION. CARDIOVASCULAR GENETICS 2014; 7:444-54. [PMID: 25031303 PMCID: PMC4332820 DOI: 10.1161/circgenetics.114.000505] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Myocarditis is an inflammatory disease of the cardiac muscle and is mainly caused by viral infections. Viral myocarditis has been proposed to be divided into 3 phases: the acute viral phase, the subacute immune phase, and the chronic cardiac remodeling phase. Although individualized therapy should be applied depending on the phase, no clinical or experimental studies have found biomarkers that distinguish between the 3 phases. Theiler's murine encephalomyelitis virus belongs to the genus Cardiovirus and can cause myocarditis in susceptible mouse strains. METHODS AND RESULTS Using this novel model for viral myocarditis induced with Theiler's murine encephalomyelitis virus, we conducted multivariate analysis including echocardiography, serum troponin and viral RNA titration, and microarray to identify the biomarker candidates that can discriminate the 3 phases. Using C3H mice infected with Theiler's murine encephalomyelitis virus on 4, 7, and 60 days post infection, we conducted bioinformatics analyses, including principal component analysis and k-means clustering of microarray data, because our traditional cardiac and serum assays, including 2-way comparison of microarray data, did not lead to the identification of a single biomarker. Principal component analysis separated heart samples clearly between the groups of 4, 7, and 60 days post infection. Representative genes contributing to the separation were as follows: 4 and 7 days post infection, innate immunity-related genes, such as Irf7 and Cxcl9; 7 and 60 days post infection, acquired immunity-related genes, such as Cd3g and H2-Aa; and cardiac remodeling-related genes, such as Mmp12 and Gpnmb. CONCLUSIONS Sets of molecules, not single molecules, identified by unsupervised principal component analysis, were found to be useful as phase-specific biomarkers.
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Affiliation(s)
- Seiichi Omura
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Eiichiro Kawai
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Fumitaka Sato
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Nicholas E Martinez
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Ganta V Chaitanya
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Phoebe A Rollyson
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Urska Cvek
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Marjan Trutschl
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - J Steven Alexander
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.)
| | - Ikuo Tsunoda
- From the Departments of Microbiology and Immunology (S.O., E.K., F.S., N.E.M., I.T.) and Molecular and Cellular Physiology (G.V.C., J.S.A.), Louisiana State University Health Sciences Center, Shreveport; and Department of Computer Science, Louisiana State University Shreveport (P.A.R., U.C., M.T.).
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Cardiovascular toxicity and titin cross-reactivity of affinity-enhanced T cells in myeloma and melanoma. Blood 2013; 122:863-71. [PMID: 23770775 DOI: 10.1182/blood-2013-03-490565] [Citation(s) in RCA: 821] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
An obstacle to cancer immunotherapy has been that the affinity of T-cell receptors (TCRs) for antigens expressed in tumors is generally low. We initiated clinical testing of engineered T cells expressing an affinity-enhanced TCR against HLA-A*01-restricted MAGE-A3. Open-label protocols to test the TCRs for patients with myeloma and melanoma were initiated. The first two treated patients developed cardiogenic shock and died within a few days of T-cell infusion, events not predicted by preclinical studies of the high-affinity TCRs. Gross findings at autopsy revealed severe myocardial damage, and histopathological analysis revealed T-cell infiltration. No MAGE-A3 expression was detected in heart autopsy tissues. Robust proliferation of the engineered T cells in vivo was documented in both patients. A beating cardiomyocyte culture generated from induced pluripotent stem cells triggered T-cell killing, which was due to recognition of an unrelated peptide derived from the striated muscle-specific protein titin. These patients demonstrate that TCR-engineered T cells can have serious and not readily predictable off-target and organ-specific toxicities and highlight the need for improved methods to define the specificity of engineered TCRs.
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