Three cases of myocarditis in childhood associated with human parvovirus (B19 virus)

Cardiac arrhythmias in viral infections

BACKGROUND

The current COVID-19 pandemic has led to many studies examining its arrhythmogenic effects. However, there are many other viruses that are capable of inducing arrhythmias that have not received as much attention. The objective of this study was to review common viruses and identify studies highlighting their arrhythmogenic effects.

METHODS AND RESULTS

In this review, we examined 15 viruses and the literature regarding their arrhythmogenic effects. The common mechanisms of action appear to be direct invasion of myocytes leading to immune mediated damage, infection of vascular endothelium, and alteration of cardiac ion channels.

CONCLUSIONS

This review highlights the growing evidence that supports the involvement of other viral infections in the development of arrhythmia. Physicians should be aware of these potentially life-threatening effects when caring for patients with these viruses, some of which are very common. Additional studies are required to better understand the complex mechanism and risk factors of cardiac arrhythmias in patients suffered from viral infections to determine whether the processes can be reversed or even prevented.

Parvovirus B19-Associated Myocarditis: A Literature Review of Pediatric Cases

Parvovirus B19 (B19V) infection may lead to myocarditis, a life-threatening condition in pediatric patients. In this review, we aim to present published pediatric cases of B19V-associated myocarditis in order to understand the deep complex connections and draw useful conclusions. We performed a comprehensive search of MEDLINE, Science Direct, and Google Scholar electronic databases. A total of 32 cases were included in our study. The most common presenting symptom was tachycardia in 22/32 patients (68.7%), followed by tachypnoea (21/32, 65.6%), fever, and rash (12/32, 37.5% for both of them). Cardiac arrest, loss of consciousness, and systemic infection were associated with the worst prognosis, with statistically significant differences (p-value 0.001, 0.02, 0.001. respectively). A percentage as high as 90.4% of patients with left ventricular (LV) dysfunction and reduced ejection fraction (EF) were discharged. Twelve patients required ventilatory support, five required extracorporeal membrane oxygenation (ECMO), and three underwent heart surgery. Treatment with immunosuppressive agents and immunoglobulin was found to be beneficial for patients (p-value 0.006 and 0.004, respectively). In conclusion, B19V myocarditis has high mortality rates in children. There is no specific antiviral treatment for B19V infection and therapeutic strategies for myocarditis aim to delay the worsening of heart failure and to preserve the LV function. Inotropic drugs, diuresis, ventilatory support, Intravenous immunoglobulin (IVIG), and immunosuppressive therapy seem to help the recovery of the myocardium in children with LV dilation, dysfunction, and reduced EF. Children with cardiac arrest, arrhythmias, and loss of consciousness have the worst prognosis.

Parvovirus B19 myocarditis in children: an observational study

BACKGROUND

The advent of PCR testing for the presence of viral genomes has led to the identification of parvovirus B19 (PVB19) as a causative agent of myocarditis.

METHODS

The clinical presentation, course and outcome of children with PVB19 myocarditis was ascertained through a retrospective review. The PVB19 viral genome was detected by PCR from whole blood or endomyocardial biopsy specimens in patients presenting with new onset heart failure.

RESULTS

Seventeen patients presented at a median age of 1.3 years (range: 0.4-15.4 years) in cardiac failure with a mean fractional shortening of 15±3%. Eleven patients required mechanical ventilation and intravenous inotropes and seven required extra-corporeal mechanical oxygenation. Four of the five deaths occurred in patients who had a short prodromal illness of less than 48 hours. All patients with ST segment elevation died (n=4). All non-fulminant cases survived. Event-free survival occurred in 11/17 (65%) patients. Five (29%) patients died and one patient underwent heart transplantation. Complete recovery of cardiac function occurred within a median of 12 months (range: 1-48) in five patients. There was incomplete recovery in five patients and one patient had persistent dilated cardiomyopathy.

CONCLUSIONS

PVB19 can cause a devastating myocarditis in children. Children with fulminant myocarditis, ST segment changes or a short prodrome have the worst outcome. Transplantation may be considered, but is rarely required in the acute period if mechanical circulatory support is utilised. If the initial presentation is survived, recovery of the myocardium can occur even in those who had fulminant myocarditis.

Parvovirus B19 Achievements and Challenges

Parvovirus B19 is a widespread human pathogenic virus, member of the Erythrovirus genus in the Parvoviridae family. Infection can be associated with an ample range of pathologies and clinical manifestations, whose characteristics and outcomes depend on the interplay between the pathogenetic potential of the virus, its adaptation to different cellular environments, and the physiological and immune status of the infected individuals. The scope of this review is the advances in knowledge on the biological characteristics of the virus and of virus-host relationships; in particular, the interactions of the virus with different cellular environments in terms of tropism and ability to achieve a productive replicative cycle, or, on the contrary, to establish persistence; the consequences of infection in terms of interference with the cell physiology; the process of recognition of the virus by the innate or adaptive immune system, hence the role of the immune system in controlling the infection or in the development of clinical manifestations. Linked to these issues is the continuous effort to develop better diagnostic algorithms and methods and the need for development of prophylactic and therapeutic options for B19V infections.

The management of myocarditis

Despite considerable advances in our understanding of myocarditis pathogenesis, the clinical management of myocarditis has changed relatively little in the last few years. This review aims to help bridge the widening gap between recent mechanistic insights, which are largely derived from animal models, and their potential impact on disease burden. We illustrate the pathogenetic mechanisms that are prime targets for novel therapeutic interventions. Pathway and pathogen-specific molecular diagnostic tests have expanded the role for endomyocardial biopsy. State of the art cardiac magnetic resonance imaging can now provide non-invasive tissue characterization and localize inflammatory infiltrates but imaging techniques are misleading if infectious agents are involved. We emphasize the gaps in our current clinical knowledge, particularly with respect to aetiology-based therapy, and suggest opportunities for high impact, translational investigations.

Parvovirus-mediated fetal cardiomyopathy with atrioventricular nodal disease

Acute parvovirus B19 infection (API) in pregnancy has been associated with fetal anemia and hydrops fetalis. Direct myocardial damage from API in a fetus and an infant has been described. This report presents a case of fetal second-degree heart block and cardiomyopathy secondary to API. A 19-year-old G4P1112 (gravida 4 para 2 with 1 term delivery, 1 preterm delivery, 1 termination, and 2 living children) was referred at 20 weeks gestation for fetal bradycardia. A 2:1 atrioventricular block was identified by fetal echocardiography at 23 weeks. Hydrops developed at 25 weeks. Amniocentesis and percutaneous umbilical blood sampling demonstrated API. At 31 weeks, the patient presented with preterm labor and delivered a viable female infant, who died of poor cardiac function and arrhythmia on the first day of life. In addition to fetal anemia and hydrops fetalis, API in pregnancy may cause direct fetal myocardial damage and conduction system disease.

Childhood myocarditis and parvovirus B19 genotypes

BACKGROUND

Human parvovirus B19 (PVB19) infection is occasionally associated with acute myocarditis. Three cases of children with PVB19 virus-associated myocarditis occurred in a very short period and the same geographical region.

OBJECTIVE

To elucidate if virological factors could be responsible for determining the course of infection, a molecular epidemiologic investigation was performed.

STUDY DESIGN

The diagnosis of myocarditis was established by histology or echocardiography. In the three cases, the PVB19 DNA was detected in different samples. Eight different regions were amplified by PCR using a high fidelity Taq polymerase and sequenced on both strands. Phylogenetic analyses were performed. First, the genotypes of the PVB19 strains were determined, then the intra-patient viral variability was analysed by sequencing PVB19 detected in different specimens sampled from the same patient at the same moment.

RESULTS

Nearly complete sequences of the PVB19 virus (4265nt) were obtained from different samples in the three patients. The phylogenetic analyses showed that PVB19 strains identified clustered with genotype 1a PVB19 strains referenced in GenBank. When compared to the referenced strain NC_000883, the number of substitutions (transitions and transversions) were as follows: 58 for Caen.FRA/19.09, 74 for Caen.FRA/21.09 and 60 for Caen.FRA/24.09. The strains isolated from the same patient showed 100% of similarity.

CONCLUSIONS

Viral myocarditis is a frequently unrecognized cause of post-inflammatory cardiomyopathy. The detailed molecular analyses do not give rise to virological markers associated with myocarditis in these children.

Pericarditis and pleuritis associated with human parvovirus B19 infection in a systemic lupus erythematosus patient

Human parvovirus B19 (PVB19) infection sometimes shows systemic lupus erythematosus (SLE)-like symptoms. We present an SLE patient showing pericarditis and pleuritis with a fever and an acute swelling of extremities 2 months after the fist consultation. Initially, a diagnosis of SLE exacerbation was made. Additional laboratory examination showed positive results for immunoglobulin M (IgM) antibody to PVB19 and PVB19 DNA in serum and pleural effusion at that time. After 1 month, PVB19 DNA in serum and IgM antibody to PVB19 was negative. Based on these findings, a final diagnosis of PVB19 infection in an SLE patient was made. PVB19 infection should be taken into consideration for SLE with acute swelling of the extremities and fever, as these symptoms are often observed in adult cases of PVB19 infection. Steroid pulse therapy rapidly improved these symptoms, and later the dose of steroid was reduced to 5 mg/day of prednisolone. Thus, steroids may be one of the choices for severe and/or rapidly progressive symptoms of pericarditis and pleuritis due to PVB19 infection.

Fatal parvoviral myocarditis: a case report and review of literature

Background

Histologically documented cases of parvoviral myocarditis are exceedingly rare.

Case presentation

Here, we report a 41-year old African American immunocompetent patient who died of parvoviral myocarditis after a 10 day illness characterized by fever, headaches, generalized arthralgias, and a maculopapular rash.

Autopsy revealed an infiltrate myocarditis composed primarily of T-lymphocytes and macrophages associated with extensive myocardial fibrosis. The diagnosis of parvovirus was determined by polymerase chain reaction (PCR) on both pre-mortem serum and post-mortem myocardial tissue

Methods

DNA was extracted from tissue and serum and primers were used to amplify DNAsequences of parvovirus B19 using nested polymerase chain reaction (PCR).

Conclusion

The diagnosis of parvovirus should be considered in cases of fatal myocarditis, and diagnosis can be confirmed at autopsy by molecular techniques.

Life threatening parvovirus B19 and herpes simplex virus associated acute myocardial dysfunction in a child with homozygous sickle cell disease

Human parvovirus (HPV) B19, a common infection, frequently causes transient red cell aplasia in children with hemolytic anemia, such as sickle cell disease (SCD). It was considered to be a self-limited condition, easily treated with blood transfusion. However, acute splenic sequestration, acute chest syndrome, nephrotic syndrome, and stroke have been reported in SCD patients following HPV B19 infection. We report a 3-year-old child with SCD who developed fulminant myocarditis following HPV B19-related aplastic crisis. The diagnosis of myocarditis should be considered in a patient with hemolytic anemia with an infection with HPV B19 who develops signs of cardiopulmonary failure despite correction of anemia.

Parvovirus B19 infection associated with dilated cardiomyopathy in patients with previous anthracycline exposure

We describe two children with previous anthracycline exposure for cancer who presented with acute decompensated left ventricular dysfunction. Both patients had evidence of dilated cardiomyopathy and required mechanical ventilation and inotropic support. Parvovirus B19 was detected by polymerase chain reaction of the blood. After several weeks of ventilation and inotropic support, both patients were weaned from ventilation and managed with oral carvedilol, ACE inhibition, and diuretics. Acute left ventricular decompensation in patients following anthracycline exposure may not be solely attributed to drug exposure, and viral etiologies should be considered.

Parvovirus B19: the causative agent of dilated cardiomyopathy or a harmless passenger of the human myocard?

Parvovirus B19 infections may cause a widespread benign and self-limiting disease in children and adults known as erythema infectiosum (fifth disease). Several further manifestations are associated with B19 infections, such as arthralgias, arthritis, leucopenia and thrombocytopenia, anaemia and vasculitis and spontaneous abortion and hydrops fetalis in pregnant women. Persistent infections with continuous virus production may occur in immunocompetent as well as in immunosuppressed individuals. Parvovirus B19 infections have been frequently implicated as a cause or trigger of various forms of autoimmune diseases affecting joints, connective tissue and large and small vessels. Autoimmune neutropenia, thrombocytopenia and haemolytic anaemia are known as sequelae of B19 infections. The molecular basis of the autoimmune phenomena is unclear. Many patients with these long-lasting symptoms are not capable of eliminating the virus or controlling its propagation. Furthermore, latent viral genomes have been detected in cells of various organs and tissues by PCR. At present, it is not clear if these cells produce viral proteins and/or infectious B19 particles, if the virus genome can be reactivated to productive replication and if the presence of viral DNA indicates a causative role of parvovirus B19 with distinct diseases.

Life-threatening cutaneous viral diseases

Most viral infections present with a cutaneous eruption that in the greater majority of cases is self-healing. Only in rare instances is the eruption accompanied by constitutional symptoms, and even more rarely, irreversible damage may occur or death may ensue. As with other infectious diseases, prognosis depends on the status of immunologic surveillance. Immunodepressed patients are, therefore, at the greatest risk. It has become more evident, however, that even in immunocompetent patients, eruption that were considered not long ago as benign diseases may in fact result in complications and even death. The introduction of polymerase chain reaction assays has allowed us to attribute conditions to a specific viral infection, which in the past was not possible. Therefore, dermatologists may come across, directly or during consultation, patients presenting with skin lesions that may be related to a viral disease and may lead to possible severe systemic complications. Dermatologists, however, may not be prepared for such developments, and thus the goal of this article is to suggest some of the possibilities. Discussing all the viral diseases that may present with cutaneous manifestations would be cumbersome; thus this article will be limited to the diseases that may endanger the life of a patient who is seeking dermatologic advice and who does not seem to have, at first sight, severe systemic involvement.

Sudden cardiac death in a 5-year-old girl associated with parvovirus B19 infection

We report on a 5-year-old girl who suddenly collapsed and died while dancing at a family party. Histological examination of the heart including the cardiac conduction system revealed lymphocytic infiltrations of the sinu-atrial node and perivascular infiltration in the atrio-ventricular region. Additionally, foci of mononuclear infiltrates were observed in the myocardium. Consequently, myocarditis was diagnosed as cause of death. The child also had lymphocytic conjunctivis, parotitis and tracheitis. Evaluation of infections by means of nested polymerase chain reaction revealed parvovirus B19 DNA (PVB19) in tissue samples of the trachea.