1
|
Grimaldi F, Bonasoni MP, Pelletti G, Gabrielli L, Pelotti S. Diagnostic challenges and forensic implications in a case of infantile fatal myocarditis. Forensic Sci Med Pathol 2024; 20:219-225. [PMID: 37335504 PMCID: PMC10944382 DOI: 10.1007/s12024-023-00659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/21/2023]
Abstract
We present the case of a 23-month-old child who died less than 24 h after the onset of cardiac symptoms, despite being admitted to the hospital 72 h earlier. Autopsy revealed no significant macroscopic changes, and histologic examination revealed focal lymphocytic myocarditis with myocyte disruption, diffuse alveolar damage in the exudative phase, and generalized lymphocytic immune activation in other organs. Ante-mortem and post-mortem microbiological exams did not clearly prove a causative role of infectious agents. The peculiarity of this case was characterized by the contrast between the severe clinical features and the mild cardiac histological findings. This discrepancy, coupled with the suspicion of a viral causative role based on both ante-mortem and post-mortem microbiological examinations, presented significant challenges in reaching an etiological diagnosis. This case also confirms that the diagnosis of myocarditis in children cannot be made solely on the basis of histological cut-offs or microbiological results. Using abductive reasoning, various diagnostic hypotheses were formulated and evaluated to arrive at the final diagnosis of fatal myocarditis of viral or post-viral origin. Data from post-mortem examination are often the only source of information that is available to the experts, especially in cases of sudden infant death syndrome. In such cases, the forensic pathologists should accurately evaluate findings that may appear to indicate a different etiology, and, in the absence of clinical or radiological data, interpret post-mortem data in a logically correct manner. The autopsy is the first essential step to evaluate the cause of death and must be integrated with the results of ante- and post-mortem diagnostic tests in a holistic approach, which is crucial to allow forensic pathologists to provide an appropriate and relevant opinion.
Collapse
Affiliation(s)
- Federica Grimaldi
- Unit of Legal Medicine, Department of Medical and Surgical Science, University of Bologna, Bologna, 40126, Italy
| | - Maria Paola Bonasoni
- Unit of Legal Medicine, Department of Medical and Surgical Science, University of Bologna, Bologna, 40126, Italy
- Pathology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, 42122, Italy
| | - Guido Pelletti
- Unit of Legal Medicine, Department of Medical and Surgical Science, University of Bologna, Bologna, 40126, Italy.
| | - Liliana Gabrielli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, 40138, Italy
| | - Susi Pelotti
- Unit of Legal Medicine, Department of Medical and Surgical Science, University of Bologna, Bologna, 40126, Italy
| |
Collapse
|
2
|
Naseeb MW, Adedara VO, Haseeb MT, Fatima H, Gangasani S, Kailey KR, Ahmed M, Abbas K, Razzaq W, Qayyom MM, Abdin ZU. Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review. Cureus 2023; 15:e40439. [PMID: 37456487 PMCID: PMC10349211 DOI: 10.7759/cureus.40439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Giant cell myocarditis (GCM) is a rare, often rapidly progressive, and potentially fatal disease because of myocardium inflammation due to the infiltration of giant cells triggered by infectious as well as non-infectious etiologies. Several studies have reported that GCM can occur in patients of all ages but is more commonly found in adults. It is relatively more common among African American and Hispanic patients than in the White population. Early diagnosis and treatment are critical. Electrocardiogram (EKG), complete blood count, erythrocyte sedimentation rate, C-reactive protein, and cardiac biomarkers such as troponin and brain natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (MRI), myocardial biopsy, and myocardial gene profiling are useful diagnostic tools. Current research has identified several potential biomarkers for GCM, including myocarditis-associated immune cells, cytokines, and other chemicals. The standard of care for GCM includes aggressive immunosuppressive therapy with corticosteroids and immunomodulatory agents like rituximab, cyclosporine, and infliximab, which have shown promising results in GCM by balancing the immune system and preventing the attack on healthy tissues, resulting in the reduction of inflammation, promotion of healing, and decreasing the necessity for cardiac transplantation. Without immunosuppression, the chance of mortality or cardiac surgery was 100%. Multiple studies have revealed that a treatment combination of corticosteroids and immunomodulatory agents is superior to corticosteroids alone. Combination therapy significantly increased transplant-free survival (TFS) and decreased the likelihood of heart transplantation, hence improving overall survival. It is important to balance the benefits of immunosuppression with its potentially adverse effects. In conclusion, immunomodulatory therapy adds significant long-term survival benefits to GCM.
Collapse
Affiliation(s)
| | - Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | | | - Hareem Fatima
- Internal Medicine, Federal Medical College, Islamabad, PAK
| | - Swapna Gangasani
- Internal Medicine, New York Medical College (NYMC) St. Mary's General Hospital and Saint Clare's Hospitals, New Jersey, USA
| | - Kamaljit R Kailey
- Medicine and Surgery, Gian Sagar Medical College and Hospital, Patiala, IND
| | - Moiz Ahmed
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
| | | | | | - Zain U Abdin
- Medicine, District Headquarter Hospital, Faisalabad, PAK
| |
Collapse
|
3
|
Kyaw T, Drummond G, Bobik A, Peter K. Myocarditis: causes, mechanisms, and evolving therapies. Expert Opin Ther Targets 2023; 27:225-238. [PMID: 36946552 DOI: 10.1080/14728222.2023.2193330] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Myocarditis is a severe lymphocyte-mediated inflammatory disorder of the heart, mostly caused by viruses and immune checkpoint inhibitors (ICIs). Recently, myocarditis as a rare adverse event of mRNA vaccines for SARS-CoV-2 has caused global attention. The clinical consequences of myocarditis can be very severe, but specific treatment options are lacking or not yet clinically proven. AREAS COVERED This paper offers a brief overview of the biology of viruses that frequently cause myocarditis, focusing on mechanisms important for viral entry and replication following host infection. Current and new potential therapeutic targets/strategies especially for viral myocarditis are reviewed systematically. In particular, the immune system in myocarditis is dissected with respect to infective viral and non-infective, ICI-induced myocarditis. EXPERT OPINION Vaccination is an excellent emerging preventative strategy for viral myocarditis, but most vaccines still require further development. Anti-viral treatments that inhibit viral replication need to be considered following viral infection in host myocardium, as lower viral load reduces inflammation severity. Understanding how the immune system continues to damage the heart even after viral clearance will define novel therapeutic targets/strategies. We propose that viral myocarditis can be best treated using a combination of antiviral agents and immunotherapies that control cytotoxic T cell activity.
Collapse
Affiliation(s)
- Tin Kyaw
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Centre for Inflammatory Diseases, Monash Medical Centre, Monash University, Melbourne, Australia
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
| | - Grant Drummond
- Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University Melbourne Australia
- Centre for Cardiovascular Biology and Disease Research, La Trobe University, Melbourne, Australia
| | - Alex Bobik
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Centre for Inflammatory Diseases, Monash Medical Centre, Monash University, Melbourne, Australia
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
- Centre for Cardiovascular Biology and Disease Research, La Trobe University, Melbourne, Australia
- Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Karlheinz Peter
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
- Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University Melbourne Australia
- Heart Centre, Alfred Hospital, Melbourne, Australia
- Department of Immunology, Monash University Melbourne Australia
| |
Collapse
|
4
|
Rasquinha MT, Lasrado N, Petro-Turnquist E, Weaver E, Venkataraman T, Anderson D, Laserson U, Larman HB, Reddy J. PhIP-Seq Reveals Autoantibodies for Ubiquitously Expressed Antigens in Viral Myocarditis. BIOLOGY 2022; 11:biology11071055. [PMID: 36101433 PMCID: PMC9312229 DOI: 10.3390/biology11071055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Simple Summary Myocarditis is the inflammation of the heart muscle, and viral infections are a common cause of this disease. Myocarditis in some patients can progress to dilated cardiomyopathy (DCM). The mouse model of coxsackievirus B3 (CVB3) is commonly used to understand this disease progression in DCM patients. In this paper, we have attempted to analyze antibodies for heart antigens that could be produced as a result of heart damage in animals infected with CVB3 using a technique called Phage ImmunoPrecipitation Sequencing (PhIP-Seq). The analyses led us to identify antibodies for several proteins that were not previously reported that may have relevance to human disease. Abstract Enteroviruses such as group B coxsackieviruses (CVB) are commonly suspected as causes of myocarditis that can lead to dilated cardiomyopathy (DCM), and the mouse model of CVB3 myocarditis is routinely used to understand DCM pathogenesis. Mechanistically, autoimmunity is suspected due to the presence of autoantibodies for select antigens. However, their role continues to be enigmatic, which also raises the question of whether the breadth of autoantibodies is sufficiently characterized. Here, we attempted to comprehensively analyze the autoantibody repertoire using Phage ImmunoPrecipitation Sequencing (PhIP-Seq), a versatile and high-throughput platform, in the mouse model of CVB3 myocarditis. First, PhIP-Seq analysis using the VirScan library revealed antibody reactivity only to CVB3 in the infected group but not in controls, thus validating the technique in this model. Second, using the mouse peptide library, we detected autoantibodies to 32 peptides from 25 proteins in infected animals that are ubiquitously expressed and have not been previously reported. Third, by using ELISA as a secondary assay, we confirmed antibody reactivity in sera from CVB3-infected animals to cytochrome c oxidase assembly factor 4 homolog (COA4) and phosphoinositide-3-kinase adaptor protein 1 (PIK3AP1), indicating the specificity of antibody detection by PhIP-Seq technology. Fourth, we noted similar antibody reactivity patterns in CVB3 and CVB4 infections, suggesting that the COA4- and PIK3AP1-reactive antibodies could be common to multiple CVB infections. The specificity of the autoantibodies was affirmed with influenza-infected animals that showed no reactivity to any of the antigens tested. Taken together, our data suggest that the autoantibodies identified by PhIP-Seq may have relevance to CVB pathogenesis, with a possibility that similar reactivity could be expected in human DCM patients.
Collapse
Affiliation(s)
- Mahima T. Rasquinha
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68583, USA; (M.T.R.); (N.L.)
| | - Ninaad Lasrado
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68583, USA; (M.T.R.); (N.L.)
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Erika Petro-Turnquist
- Nebraska Center for Virology, University of Nebraska-Lincoln, Lincoln, NE 68583, USA; (E.P.-T.); (E.W.)
| | - Eric Weaver
- Nebraska Center for Virology, University of Nebraska-Lincoln, Lincoln, NE 68583, USA; (E.P.-T.); (E.W.)
| | - Thiagarajan Venkataraman
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA;
| | - Daniel Anderson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA;
| | - Uri Laserson
- Department of Genetics and Genomic Sciences and Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - H. Benjamin Larman
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA;
- Correspondence: (H.B.L.); (J.R.); Tel.: +1-(410)-614-6525 (H.B.L); +1-(402)-472-8541 (J.R.)
| | - Jay Reddy
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68583, USA; (M.T.R.); (N.L.)
- Correspondence: (H.B.L.); (J.R.); Tel.: +1-(410)-614-6525 (H.B.L); +1-(402)-472-8541 (J.R.)
| |
Collapse
|
5
|
Esposito S, Caminiti C, Giordano R, Argentiero A, Ramundo G, Principi N. Myocarditis Following COVID-19 Vaccine Use: Can It Play a Role for Conditioning Immunization Schedules? Front Immunol 2022; 13:915580. [PMID: 35833128 PMCID: PMC9271782 DOI: 10.3389/fimmu.2022.915580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Myocarditis (MYO) is a relatively uncommon inflammatory disease that involves the heart muscle. It can be a very severe disease as it can lead to the development of acute or chronic heart failure and, in a not marginal number of cases, to death. Most of the cases are diagnosed in healthy people younger than 30 years of age. Moreover, males are affected about twice as much as females. Viruses are among the most common causes of MYO, but how viral infection can lead to MYO development is not precisely defined. After COVID-19 pandemic declaration, incidence rate of MYO has significantly increased worldwide because of the SARS-CoV-2 infection. After the introduction of anti-COVID-19 vaccines, reports of post-immunization MYO have emerged, suggesting that a further cause of MYO together with the SARS-CoV-2 infection could increase the risk of heart damage during pandemic. Main aim of this study is to discuss present knowledge regarding etiopathogenesis and clinical findings of MYO associated with COVID-19 vaccine administration and whether the risk of this adverse events can modify the initially suggested recommendation for the use of COVID-19 vaccines in pediatric age. Literature analysis showed that MYO is an adverse event that can follow the COVID-19 immunization with mRNA vaccines in few persons, particularly young adults, adolescents, and older children. It is generally a mild disease that should not modify the present recommendations for immunization with the authorized COVID-19 mRNA vaccines. Despite this, further studies are needed to evaluate presently undefined aspects of MYO development after COVID-19 vaccine administration and reduce the risk of development of this kind of vaccine complication. Together with a better definition of the true incidence of MYO and the exact role of the various factors in conditioning incidence variations, it is essential to establish long-term evolution of acute COVID-19 related MYO.
Collapse
Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
- *Correspondence: Susanna Esposito,
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | | | - Alberto Argentiero
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Greta Ramundo
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | | |
Collapse
|
6
|
Parvovirus B19 infection during pregnancy. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2022. [DOI: 10.2478/cipms-2022-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Parvovirus B19 (B19V) is a widespread pathogen causing infection that occurs mostly in children. Even though infection of B19V is mainly asymptomatic, it can bring about a few conditions that may require medical intervention, including erythema infectiosum (fifth disease), slapped cheek syndrome, papular-purpuric gloves and socks syndrome (PPGSS), as well as other disorders related to the hematological system. Despite the fact that the most common route of transmission is through the respiratory system, B19V can be also transmitted transplacentally from mother to foetus. Vertical transmission may lead to myocarditis, thrombocytopenia, neural manifestations, and foetal hydrops, which may be life-threatening conditions to both mother and foetus. Detection of B19V infection is based mostly on molecular and serological screening and it is performed after suspected exposure to pathogen or exhibition of symptoms. Currently, there is no specific medication against B19V infection, therefore, treatment is based on the elimination of symptoms. New therapies are, however, under development.
Collapse
|
7
|
Esmel-Vilomara R, Dolader P, Izquierdo-Blasco J, Balcells J, Sorlí M, Escudero F, Vera E, Gran F. Parvovirus B19 myocarditis in children: a diagnostic and therapeutic approach. Eur J Pediatr 2022; 181:2045-2053. [PMID: 35138467 DOI: 10.1007/s00431-022-04406-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED Parvovirus B19 is one of the most frequent causes of pediatric myocarditis, associating high mortality rates or need for cardiac transplantation. The aim of this study is to describe the clinical course of Parvovirus B19 myocarditis in children with emphasis on the role of endomyocardial biopsy and cardiac magnetic resonance, and the use of an innovative therapeutic strategy. Eleven patients and 12 episodes of polymerase chain reaction (PCR)-confirmed Parvovirus B19 myocarditis were prospectively collected for 14 years. Diagnosis was confirmed either histopathologically or by magnetic resonance. A life-threatening clinical presentation is described, similar to previous series, but with 83.3% overall survival without transplantation. We also present a case of recurrent myocarditis, which is extraordinarily rare. Electrocardiographic patterns presented chiefly peaked p waves, low QRS voltages, and negative T waves on inferior or lateral leads. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance could be a useful diagnostic tool. A good concordance between myocardial and blood PCRs was observed. Seven patients received treatment with corticosteroids and beta interferon and all underwent a significant cardiac function improvement. CONCLUSION A severe clinical presentation is reported, similar to previous reports but with better outcomes. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance may be used. Both blood and myocardium PCR can be used in children to establish the microbiological etiology. Steroids with IFNß could be a useful therapeutic option, although further multicenter studies are needed to confirm these results. WHAT IS KNOWN • Parvovirus B19 is one of the most frequent causes of myocarditis in children. It is associated with a fulminant clinical presentation. • Endomyocardial biopsy is the gold standard diagnostic test but it is an invasive procedure. WHAT IS NEW • Myocarditis may recur in pediatrics, even it is extraordinarily rare. • IFNβ with steroids may be a useful therapeutic option to improve the outcomes.
Collapse
Affiliation(s)
- Roger Esmel-Vilomara
- Pediatric Cardiology, Vall d'Hebron Hospital Campus, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Pediatric Cardiology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain.
| | - Paola Dolader
- Pediatric Cardiology, Vall d'Hebron Hospital Campus, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | | | - Joan Balcells
- Pediatric Critical Care, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - Moisés Sorlí
- Pediatric Cardiology, Hospital Virgen de La Arrixaca, Murcia, Spain
| | | | - Elena Vera
- Pediatric Cardiology, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| | - Ferran Gran
- Pediatric Cardiology, Vall d'Hebron Hospital Campus, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| |
Collapse
|
8
|
Moisa SM, Miron IC, Tarca E, Trandafir L, Lupu VV, Lupu A, Rusu TE. Non-Cardiac Cause of Death in Selected Group Children with Cardiac Pathology: A Retrospective Single Institute Study. CHILDREN 2022; 9:children9030335. [PMID: 35327707 PMCID: PMC8946943 DOI: 10.3390/children9030335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 12/05/2022]
Abstract
Background: Pediatricians and pediatric surgeons often face children with cardiomegaly and dilatative or hypertrophic cardiomyopathies presenting with or without symptoms. Some of these patients have already been diagnosed and received medication, and some present with completely unrelated pathologies. Methods: We performed a 4-year retrospective study on the causes and mechanisms of death of children with cardiac pathology who died outside the cardiology clinic of our hospital by studying the hospital charts and necropsy reports. All children who were in this situation in our hospital were included. Results: Most children in our study group were infants (81.82%), most were boys (81.82%), and in most cases, the cause or mechanism of death was unrelated to their heart condition, whether it had already been diagnosed or not (one case probably died as a result of a malignant ventricular arrhythmia). Additionally, 27.27% of children died as a consequence of bronchopneumonia, the same percentage died as a consequence of an acquired non-pulmonary disease or after surgery, and 18.18% died as a consequence of congenital malformations. Conclusions: Cardiac disease needs to be thoroughly investigated using multiple tools for all children presenting with heart failure symptoms, those with heart murmurs, and children scheduled for surgery of any type. The intensive care specialist and surgeon need to be aware of any heart pathology before non-cardiac surgical interventions.
Collapse
Affiliation(s)
- Stefana Maria Moisa
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
| | - Ingrith Crenguta Miron
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
| | - Elena Tarca
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
| | - Laura Trandafir
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
| | - Vasile Valeriu Lupu
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
- Correspondence: (V.V.L.); (A.L.)
| | - Ancuta Lupu
- Pediatrics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.M.M.); (I.C.M.); (E.T.); (L.T.)
- Correspondence: (V.V.L.); (A.L.)
| | | |
Collapse
|
9
|
Grohall SJ, Colon AA, Churosh JL, Bryant R, Zangwill SD. Parvovirus: From Fifth Disease to Heart Transplant. J Pediatr Health Care 2022; 36:165-169. [PMID: 34218967 DOI: 10.1016/j.pedhc.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Stacey J Grohall
- Transplant Coordinator, Phoenix Children's Hospital, Phoenix, AZ.
| | - April A Colon
- Transplant Coordinator, Phoenix Children's Hospital, Phoenix, AZ
| | | | - Roosevelt Bryant
- Cardiothoracic Surgeon, Phoenix Children's Hospital, Phoenix, AZ
| | | |
Collapse
|
10
|
Gran F, Fidalgo A, Dolader P, Garrido M, Navarro A, Izquierdo-Blasco J, Balcells J, Codina-Sola M, Fernandez-Alvarez P, Sabaté-Rotés A, Betrián P, Fernández-Doblas J, Abella R, Roses-Noguer F. Differences between genetic dilated cardiomyopathy and myocarditis in children presenting with severe cardiac dysfunction. Eur J Pediatr 2022; 181:287-294. [PMID: 34286374 PMCID: PMC8294227 DOI: 10.1007/s00431-021-04175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/18/2021] [Accepted: 06/19/2021] [Indexed: 11/24/2022]
Abstract
Acute myocarditis is an inflammatory disease of the myocardium, and it can present as severe heart failure in children. Differential diagnosis with genetic cardiomyopathy can be difficult. The objective of this study is to identify patterns of clinical presentation and to assess invasive and non-invasive measures to differentiate patients with acute myocarditis from patients with dilated genetic cardiomyopathy. We performed a retrospective descriptive study of all paediatric patients (0-16 years old) that presented with new-onset heart failure with left ventricle ejection fraction < 35% in whom we performed an endomyocardial biopsy (EMB) during the period from April 2007 to December 2020. The patients were classified into two groups: Group 1 included 18 patients with myocarditis. Group 2 included 9 patients with genetic cardiomyopathy. Findings favouring a diagnosis of myocarditis included a fulminant or acute presentation (77.8% vs 33.3%, p = 0.01), higher degree of cardiac enzyme elevation (p = 0.011), lower left ventricular dimension z-score (2.2 vs 5.4, p = 0.03) increase of ventricular wall thickness (88.8% vs 33.3%, p = 0.03) and oedema in the EMB. Seven (77.8%) patients with genetic cardiomyopathy had inflammation in the endomyocardial biopsy fulfilling the diagnostic criteria of inflammatory cardiomyopathy.Conclusion: Differentiating patients with a myocarditis from those with genetic cardiomyopathy can be challenging, even performing an EMB. Some patients with genetic cardiomyopathy fulfil the diagnostic criteria of inflammatory cardiomyopathy. Using invasive and non-invasive measures may be useful to develop a predictive model to differentiate myocarditis from genetic cardiomyopathy. What is Known: • Acute myocarditis could present with cardiogenic shock in paediatric patients. • Parvovirus B19 is the main cause of myocarditis in this population. What is New: • Current diagnostic criteria for myocarditis have limited use in paediatric patients presenting with new-onset heart failure. • Some patients with a genetic cardiomyopathy and a new-onset heart failure fulfill the diagnostic criteria of inflammatory cardiomyopathy.
Collapse
Affiliation(s)
- Ferran Gran
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Andrea Fidalgo
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Paola Dolader
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Marta Garrido
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Alexandra Navarro
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jaume Izquierdo-Blasco
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Joan Balcells
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marta Codina-Sola
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Paula Fernandez-Alvarez
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Anna Sabaté-Rotés
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Pedro Betrián
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Joaquín Fernández-Doblas
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Raúl Abella
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ferran Roses-Noguer
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| |
Collapse
|
11
|
Law YM, Lal AK, Chen S, Čiháková D, Cooper LT, Deshpande S, Godown J, Grosse-Wortmann L, Robinson JD, Towbin JA. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e123-e135. [PMID: 34229446 DOI: 10.1161/cir.0000000000001001] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myocarditis remains a clinical challenge in pediatrics. Originally, it was recognized at autopsy before the application of endomyocardial biopsy, which led to a histopathology-based diagnosis such as in the Dallas criteria. Given the invasive and low-sensitivity nature of endomyocardial biopsy, its diagnostic focus shifted to a reliance on clinical suspicion. With the advances of cardiac magnetic resonance, an examination of the whole heart in vivo has gained acceptance in the pursuit of a diagnosis of myocarditis. The presentation may vary from minimal symptoms to heart failure, life-threatening arrhythmias, or cardiogenic shock. Outcomes span full resolution to chronic heart failure and the need for heart transplantation with inadequate clues to predict the disease trajectory. The American Heart Association commissioned this writing group to explore the current knowledge and management within the field of pediatric myocarditis. This statement highlights advances in our understanding of the immunopathogenesis, new and shifting dominant pathogeneses, modern laboratory testing, and use of mechanical circulatory support, with a special emphasis on innovations in cardiac magnetic resonance imaging. Despite these strides forward, we struggle without a universally accepted definition of myocarditis, which impedes progress in disease-targeted therapy.
Collapse
|
12
|
Kontorovich AR, Patel N, Moscati A, Richter F, Peter I, Purevjav E, Selejan SR, Kindermann I, Towbin JA, Bohm M, Klingel K, Gelb BD. Myopathic Cardiac Genotypes Increase Risk for Myocarditis. JACC Basic Transl Sci 2021; 6:584-592. [PMID: 34368507 PMCID: PMC8326270 DOI: 10.1016/j.jacbts.2021.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022]
Abstract
Impairments in certain cardiac genes confer risk for myocarditis in children. To determine the extent of this association, we performed genomic sequencing in predominantly adult patients with acute myocarditis and matched control subjects. Putatively deleterious variants in a broad set of cardiac genes were found in 19 of 117 acute myocarditis cases vs 34 of 468 control subjects (P = 0.003). Thirteen genes classically associated with cardiomyopathy or neuromuscular disorders with cardiac involvement were implicated, including >1 associated damaging variant in DYSF, DSP, and TTN. Phenotypes of subjects who have acute myocarditis with or without deleterious variants were similar, indicating that genetic testing is necessary to differentiate them.
Collapse
Key Words
- ACM, arrhythmogenic cardiomyopathy
- AM, acute myocarditis
- AM1, acute myocarditis registry 1
- CMP, cardiomyopathy
- DV, deleterious variant
- EF, ejection fraction
- ES, exome sequencing
- NMD, neuromuscular disorder
- OR, odds ratio
- TGP, targeted gene panel
- acute myocarditis
- cardiomyopathy
- genetics
Collapse
Affiliation(s)
- Amy R. Kontorovich
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nihir Patel
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arden Moscati
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Felix Richter
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Enkhsaikhan Purevjav
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Simina Ramona Selejan
- Department of Internal Medicine III (Cardiology, Angiology and Intensive Care), Saarland University Medical Center, Saarland University, Homburg/Saar, Germany
| | - Ingrid Kindermann
- Department of Internal Medicine III (Cardiology, Angiology and Intensive Care), Saarland University Medical Center, Saarland University, Homburg/Saar, Germany
| | - Jeffrey A. Towbin
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael Bohm
- Department of Internal Medicine III (Cardiology, Angiology and Intensive Care), Saarland University Medical Center, Saarland University, Homburg/Saar, Germany
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bruce D. Gelb
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
13
|
Neagu O, Rodríguez AF, Callon D, Andréoletti L, Cohen MC. Myocarditis Presenting as Sudden Death in Infants and Children: A Single Centre Analysis by ESGFOR Study Group. Pediatr Dev Pathol 2021; 24:327-336. [PMID: 33872111 DOI: 10.1177/10935266211007262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute myocarditis is an inflammatory disease of the heart mostly diagnosed in young people, which can present as sudden death. The etiology includes infectious agents (mostly viruses), systemic diseases and toxins. We aim to characterize infants and children with myocarditis at post-mortem presenting as sudden deaths. METHODS Retrospective evaluation of 813 post-mortems in infants and children dying suddenly and unexpectedly between 2009-2019. Data retrieved included histological features, microbiology and clinical history. RESULTS 23 of 813 post-mortems reviewed corresponded to acute myocarditis and 1 to dilated cardiomyopathy related to remote Parvovirus infection. PCR identified enterovirus (7), parvovirus (7 cases, 2 also with HHV6 and 1 case with EVB), Influenza A (1), Parainfluenza type 3 (1). Two cases corresponded to hypersensitivity myocarditis, 1 was Group A Streptococcus and 5 idiopathic myocarditis. Enterovirus was frequent in infants (7/10), and in newborns was associated with meningoencephalitis or congenital myocarditis. More than 50% were less than 2 years of age and all remained clinically unsuspected. CONCLUSION Myocarditis represents almost 3% of all sudden pediatric deaths. Enterovirus and parvovirus were the most common viruses. This retrospective analysis showed that patients experienced viral symptoms but remained unsuspected, highlighting the need for more clinical awareness of myocarditis.
Collapse
Affiliation(s)
- Oana Neagu
- Histopathology Department, Sheffield Children's NHS FT, Sheffield, UK
| | - Amparo Fernández Rodríguez
- Forensic Microbiology Laboratory, Instituto Nacional de Toxicología y Ciencias Forenses, Madrid, Spain.,Joint Working Group of the European Society of Clinical Microbiology and Infectious Diseases Study Group of Forensic and Postmortem Microbiology and the European Society of Pathology, Basel, Switzerland
| | - Domitille Callon
- Joint Working Group of the European Society of Clinical Microbiology and Infectious Diseases Study Group of Forensic and Postmortem Microbiology and the European Society of Pathology, Basel, Switzerland.,Clinical and Molecular Virology Unit, Centre Hospitalier Universitaire, Reims, France
| | - Laurent Andréoletti
- Joint Working Group of the European Society of Clinical Microbiology and Infectious Diseases Study Group of Forensic and Postmortem Microbiology and the European Society of Pathology, Basel, Switzerland.,Clinical and Molecular Virology Unit, Centre Hospitalier Universitaire, Reims, France
| | - Marta C Cohen
- Histopathology Department, Sheffield Children's NHS FT, Sheffield, UK.,Joint Working Group of the European Society of Clinical Microbiology and Infectious Diseases Study Group of Forensic and Postmortem Microbiology and the European Society of Pathology, Basel, Switzerland.,Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| |
Collapse
|
14
|
Diagnosis and Management of Myocarditis: An Evidence-Based Review for the Emergency Medicine Clinician. J Emerg Med 2021; 61:222-233. [PMID: 34108120 DOI: 10.1016/j.jemermed.2021.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Myocarditis is a potentially fatal condition that can be misdiagnosed in the emergency department (ED) setting. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of myocarditis, with a focus on emergency clinicians. DISCUSSION Myocarditis occurs when inflammation of the heart musculature causes cardiac dysfunction. Symptoms may range from mild to severe and are often preceded by a viral prodrome. Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is the ideal test in the ED setting. Some patients may also require advanced imaging, though this will often occur during hospitalization or follow-up. Treatment is primarily focused on respiratory and hemodynamic support. Initial hemodynamic management includes vasopressors and inotropes, whereas more severe cases may require an intra-aortic balloon pump, extracorporeal membrane oxygenation, or a ventricular assist device. Nonsteroidal anti-inflammatory drugs should be avoided while intravenous immunoglobulin is controversial. CONCLUSION Myocarditis is a serious condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
Collapse
|
15
|
de Abreu CB, Muzzi RAL, de Oliveira LED, Schulien T, Coelho MDR, Alves LA, Hirsch C, Dorneles EMS, Pinto AMBG, Barreto MSO, Muzzi LAL, Nogueira RB. Systolic dysfunction by two-dimensional speckle tracking echocardiography in dogs with parvoviral enteritis. J Vet Cardiol 2021; 34:93-104. [PMID: 33631657 DOI: 10.1016/j.jvc.2021.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/14/2021] [Accepted: 01/22/2021] [Indexed: 01/25/2023]
Abstract
INTRODUCTION/OBJECTIVES Parvoviral enteritis (PVE) can cause either primary or secondary myocardial injury; the latter is associated with systemic inflammatory response syndrome and sepsis. Strain (St) and strain rate (SR) are relatively new speckle tracking echocardiographic (STE) variables used to assess myocardial function and are less influenced by preload and volume status than are conventional variables. The aim of this study was to evaluate systolic function in dogs with PVE using two-dimensional STE. ANIMALS Forty-five client-owned dogs were included. MATERIALS AND METHODS Dogs were classified into four groups: healthy (n = 9), PVE-mild (n = 15), PVE-severe (n = 13) and PVE-died (n = 8). Left ventricular global and segmental myocardial St and SR were assessed in radial, circumferential and longitudinal axes in the right parasternal transverse and apical 4-chamber views. In the circumferential and longitudinal axes, the value of each segment was determined separately at the endocardial and epicardial levels. RESULTS Compared to healthy animals, all dogs with PVE showed significantly impaired St and SR values, mainly for PVE-severe and PVE-died groups. Moreover, the lowest SR value was observed in the circumferential axis at the mid-septal epicardial segment in the PVE-died group. For this variable, a cut-off value of 0.95 s-1 demonstrated 100% sensitivity and specificity for distinguishing between PVE-severe and PVE-died groups. CONCLUSIONS In the present study, all dogs with PVE developed systolic dysfunction, which was more severe in non-survivors. Assessment of St and SR in dogs with PVE might be clinically useful for evaluating haemodynamic status and developing suitable therapeutic strategies to improve prognosis.
Collapse
Affiliation(s)
- C B de Abreu
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil.
| | - R A L Muzzi
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - L E D de Oliveira
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - T Schulien
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - M de R Coelho
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - L A Alves
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - C Hirsch
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - E M S Dorneles
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - A M B G Pinto
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - M S O Barreto
- Department of Veterinary Clinics and Surgery, Veterinary School, Federal University of Minas Gerais, Belo Horizonte, 31270-901, Brazil
| | - L A L Muzzi
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| | - R B Nogueira
- Department of Veterinary Medicine, Federal University of Lavras, Lavras, 37200-900, Brazil
| |
Collapse
|
16
|
Das BB, Prusty BK, Niu J, Huang ML, Zhu H, Eliassen E, Kuypers JM, Jerome KR. Detection of parvovirus B19 and human herpesvirus 6 in pediatric dilated cardiomyopathy: Impact after heart transplantation. Ann Pediatr Cardiol 2020; 13:301-308. [PMID: 33311918 PMCID: PMC7727911 DOI: 10.4103/apc.apc_124_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 05/11/2020] [Accepted: 05/29/2020] [Indexed: 01/01/2023] Open
Abstract
Objectives: The aim of this study is to evaluate HHV-6 and PVB19 infection using polymerase chain reaction (PCR) and immunofluorescent assay (IFA) in the myocardium of pediatric patients with dilated cardiomyopathy (DCM) and the impact of viral persistence in the cardiac allograft after heart transplantation (HT). Methods: Multiplex droplet digital PCR was used to analyze the prevalence of viral sequences in myocardial samples from 48 pediatric DCM patients and 10 control subjects. Of the 48 DCM patients, 44 underwent HT. After HT, consecutive endomyocardial biopsy (EMB) samples were analyzed for the presence of PVB19 and HHV-6 antigens using IFA and the patients were evaluated for rejections, coronary vasculopathy, and graft loss. Results: Of the 48 DCM patients, 14 had positive viral PCR results in explanted/autopsy hearts. Among them, PVB19 was found in 8/48, HHV6 in 4/48, both PVB19 and HHV6 in 1/48, and enterovirus in one, but no adenovirus was found. The EMB samples obtained after HT were positive for PVB19 and HHV-6 in 7/44 and 3/44 cases, respectively. Viral presence in both the explanted heart and the cardiac allograft was demonstrated in 4 patients, 3 of whom were positive for PVB19, and one of whom was positive for HHV-6 pretransplant. Coronary vasculopathy and graft loss were more common in patients with PVB19-positive myocardial tissues versus those who were PVB19-negative. Conclusions: There is an association between PVB19 and HHV-6 infection and DCM in children. The study suggests the persistence of PVB19 and HHV-6 in the host can lead to subsequent viral reactivation in the transplanted heart, even in those recipients who do not have active myocarditis. PVB19 in the cardiac allograft tended toward higher adverse post-HT events.
Collapse
Affiliation(s)
- Bibhuti B Das
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Austin, Texas, USA
| | - Bhupesh K Prusty
- Department of Microbiology, Institute for Virology and Immunobiology, University of Wuerzburg, Wuerzburg, Germany
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, FL, USA
| | - Meei-Li Huang
- Department of Laboratory Medicine, Division of Virology, University of Washington, Seattle, WA, USA
| | - Haiying Zhu
- Department of Laboratory Medicine, Division of Virology, University of Washington, Seattle, WA, USA
| | | | - Jane M Kuypers
- Department of Laboratory Medicine, Division of Virology, University of Washington, Seattle, WA, USA
| | - Keith R Jerome
- Department of Laboratory Medicine, Division of Virology, University of Washington, Seattle, WA, USA
| |
Collapse
|
17
|
Lasrado N, Reddy J. An overview of the immune mechanisms of viral myocarditis. Rev Med Virol 2020; 30:1-14. [PMID: 32720461 DOI: 10.1002/rmv.2131] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
Viral myocarditis has been identified as a major cause of dilated cardiomyopathy (DCM) that can lead to heart failure. Historically, Coxsackieviruses and adenoviruses have been commonly suspected in myocarditis/DCM patients in North America and Europe. However, this notion is changing as other viruses such as Parvovirus B19 and human herpesvirus-6 are increasingly reported as causes of myocarditis in the United States, with the most recent example being the severe acute respiratory syndrome coronavirus 2, causing the Coronavirus Disease-19. The mouse model of Coxsackievirus B3 (CVB3)-induced myocarditis, which may involve mediation of autoimmunity, is routinely used in the study of immune pathogenesis of viral infections as triggers of DCM. In this review, we discuss the immune mechanisms underlying the development of viral myocarditis with an emphasis on autoimmunity in the development of post-infectious myocarditis induced with CVB3.
Collapse
Affiliation(s)
- Ninaad Lasrado
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Jay Reddy
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| |
Collapse
|
18
|
Izquierdo-Blasco J, Salcedo Allende MT, Codina Grau MG, Gran F, Martínez Sáez E, Balcells J. Parvovirus B19 Myocarditis: Looking Beyond the Heart. Pediatr Dev Pathol 2020; 23:158-162. [PMID: 31335286 DOI: 10.1177/1093526619865641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human parvovirus B19 represents the most common etiology of myocarditis in the pediatric population. Although it usually causes a benign exanthematic viral infection, parvovirus B19 may also present as disseminated disease with tropism for the myocardium, causing heart failure with high mortality. We present the case of a 2-year-old patient with fulminating acute myocarditis in whom the histological, immunophenotypic, and microbiological findings in necropsy showed multiorgan involvement caused by parvovirus B19. The autopsy revealed changes due to infection with parvovirus B19 as well as hypoxic-ischemic and secondary autoimmune changes. Medullary aplasia was observed, transmural lymphocyte myocarditis, lymphocytosis in the dermis with endothelial cells positive for parvovirus B19 in immunohistochemistry, cholestatic hepatitis due to ischemia and autoimmune hepatitis, lymphadenitis, and signs of hemophagocytosis. We also found hypoxic-ischemic encephalopathy.
Collapse
Affiliation(s)
- Jaume Izquierdo-Blasco
- Pediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Teresa Salcedo Allende
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Gemma Codina Grau
- Department of Microbiology, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Gran
- Department of Pediatric Cardiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Martínez Sáez
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Balcells
- Pediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
19
|
Zhang L, Han B, Wang J, Liu Q, Kong Y, Jiang D, Jia H. Differential expression profiles and functional analysis of circular RNAs in children with fulminant myocarditis. Epigenomics 2019; 11:1129-1141. [PMID: 31198064 DOI: 10.2217/epi-2019-0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aim: To assess differential expression profiles of circular RNAs (circRNAs) and explore their possible functions in children with fulminant myocarditis. Materials & methods: circRNA microarray experiments were carried out for determining differential expression profiles of circRNAs in three children with fulminant myocarditis and three healthy volunteers. Functional analysis and circRNA-miRNA-mRNA interaction network building were conducted to study biological functions. Results: This work identified 2281 upregulated and 892 downregulated circRNAs. Further assessment confirmed hsa_circ_0071542 upregulation (2.5-fold) in fulminant myocarditis. Functional analysis demonstrated the differentially expressed circRNAs mainly contributed to inflammation and immunity. Conclusion: circRNAs might have substantial roles in pediatric fulminant myocarditis, and hsa_circ_0071542 could serve as a promising biomarker.
Collapse
Affiliation(s)
- Li Zhang
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Bo Han
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Jing Wang
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Qingqing Liu
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Yaru Kong
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Diandong Jiang
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| | - Hailin Jia
- Department of Pediatric Cardiology, Shandong Provincial Hospital affiliated to Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong 250021, PR China
| |
Collapse
|
20
|
Lipshultz SE, Law YM, Asante-Korang A, Austin ED, Dipchand AI, Everitt MD, Hsu DT, Lin KY, Price JF, Wilkinson JD, Colan SD. Cardiomyopathy in Children: Classification and Diagnosis: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e9-e68. [PMID: 31132865 DOI: 10.1161/cir.0000000000000682] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this scientific statement from the American Heart Association, experts in the field of cardiomyopathy (heart muscle disease) in children address 2 issues: the most current understanding of the causes of cardiomyopathy in children and the optimal approaches to diagnosis cardiomyopathy in children. Cardiomyopathies result in some of the worst pediatric cardiology outcomes; nearly 40% of children who present with symptomatic cardiomyopathy undergo a heart transplantation or die within the first 2 years after diagnosis. The percentage of children with cardiomyopathy who underwent a heart transplantation has not declined over the past 10 years, and cardiomyopathy remains the leading cause of transplantation for children >1 year of age. Studies from the National Heart, Lung, and Blood Institute-funded Pediatric Cardiomyopathy Registry have shown that causes are established in very few children with cardiomyopathy, yet genetic causes are likely to be present in most. The incidence of pediatric cardiomyopathy is ≈1 per 100 000 children. This is comparable to the incidence of such childhood cancers as lymphoma, Wilms tumor, and neuroblastoma. However, the published research and scientific conferences focused on pediatric cardiomyopathy are sparcer than for those cancers. The aim of the statement is to focus on the diagnosis and classification of cardiomyopathy. We anticipate that this report will help shape the future research priorities in this set of diseases to achieve earlier diagnosis, improved clinical outcomes, and better quality of life for these children and their families.
Collapse
|
21
|
Structure of Parvovirus B19 Decorated by Fabs from a Human Antibody. J Virol 2019; 93:JVI.01732-18. [PMID: 30787153 DOI: 10.1128/jvi.01732-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/03/2019] [Indexed: 01/16/2023] Open
Abstract
Parvovirus B19, one of the most common human pathogens, is a small DNA virus that belongs to the Parvoviridae As a result of previous infections, antibodies to B19 are present in most adults. B19 has a strong tropism to erythroid progenitor cells and is able to cause a series of medical conditions, including fifth disease, arthritis, myocarditis, hydrops fetalis, and aplastic crisis. No approved vaccine is currently available for B19, and there is a lack of structural characterization of any B19 epitopes. Here we present the first cryo-electron microscopy (cryo-EM) structure of a B19 virus-like particle (VLP) complexed with the antigen-binding fragment (Fab) of a human neutralizing antibody, 860-55D. A model was built into the 3.2-Å-resolution map, and the antigenic residues on the surface of the B19 capsid were identified. Antibody 860-55D bridges the capsid of B19 by binding to a quaternary structure epitope formed by residues from three neighboring VP2 capsid proteins.IMPORTANCE Parvovirus B19 is a common human pathogen and a particular threat to children, pregnant women, and patients with sickle cell disease or AIDS. Currently, neutralizing antibody is the most efficient treatment for acute B19 infections. Research on the antigenic properties of B19 will guide the usage of these antibodies and facilitate vaccine development. We have determined and report here the high-resolution structure of B19 virus-like particles (VLPs) complexed with the Fab of a human neutralizing antibody. The structure shows a quaternary structure epitope formed by three VP2 proteins and provides details on host recognition of human B19 virus.
Collapse
|
22
|
Obeid KM. Infections with DNA Viruses, Adenovirus, Polyomaviruses, and Parvovirus B19 in Hematopoietic Stem Cell Transplant Recipients and Patients with Hematologic Malignancies. Infect Dis Clin North Am 2019; 33:501-521. [PMID: 30940465 DOI: 10.1016/j.idc.2019.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Infections due to adenovirus, polyomaviruses (BK and JC viruses), and parvovirus B19 may not be as common as infections due to other DNA viruses, such as cytomegalovirus in patients with hematological malignancies and the recipients of hematopoietic stem cell transplantation. However, these infections may result in life-threatening diseases that significantly impact patients' recovery, morbidity, and mortality. Treating physicians should be aware of the diseases associated with these viruses, the patient populations at increased risk for complications due to these infections, and the available diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Karam M Obeid
- Division of Infectious Diseases and International Medicine, University of Minnesota, 420 Delaware Street SE, MMC250, Minneapolis, MN 55455, USA.
| |
Collapse
|
23
|
Prefumo F, Fichera A, Fratelli N, Sartori E. Fetal anemia: Diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2019; 58:2-14. [PMID: 30718211 DOI: 10.1016/j.bpobgyn.2019.01.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Fetal anemia has been known for many years as a dangerous complication of pregnancy. Its most common causes are maternal alloimmunization and parvovirus B19 infection, although it can be associated with many different pathological conditions including fetal aneuploidies, vascular tumors, and arteriovenous malformations of the fetus or placenta and inherited conditions such as alpha-thalassemia or genetic metabolic disorders. Doppler ultrasonographic assessment of the peak velocity of systolic blood flow in the middle cerebral artery for the diagnosis of fetal anemia and intravascular intrauterine transfusion for its treatment are the current practice standards. Live birth rates as high as 95% have been reported in recent years. The additional role of intravenous immunoglobulin therapy and the long-term consequences of the condition are the subjects of active ongoing research.
Collapse
Affiliation(s)
- Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy.
| | - Anna Fichera
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| |
Collapse
|
24
|
Bejiqi R, Retkoceri R, Maloku A, Mustafa A, Bejiqi H, Bejiqi R. The Diagnostic and Clinical Approach to Pediatric Myocarditis: A Review of the Current Literature. Open Access Maced J Med Sci 2019; 7:162-173. [PMID: 30740183 PMCID: PMC6352488 DOI: 10.3889/oamjms.2019.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/01/2018] [Accepted: 12/02/2018] [Indexed: 12/25/2022] Open
Abstract
Myocarditis is an inflammatory disease of the myocardium with a broad spectrum of clinical presentations, ranging from mild symptoms to severe heart failure. The course of patients with myocarditis is heterogeneous, varying from partial or full clinical recovery in a few days to advanced low cardiac output syndrome requiring mechanical circulatory support or heart transplantation. Myocarditis is a very heterogeneous disease, especially in the pediatric age group as worldwide disease myocarditis has been defined by the World Health Organization/International Society and Federation of Cardiology as an inflammatory disease of the heart muscle diagnosed by established histological, immunologic, and immunohistological criteria. Pediatric myocarditis remains challenging from the perspectives of diagnosis and management. Multiple etiologies exist, and the majority of cases appear to be related to viral illnesses. Enteroviruses are believed to be the most common cause, although cases related to adenovirus may be more frequent than suspected. The clinical presentation is extremely varied, ranging from asymptomatic to sudden unexpected death. A high index of suspicion is crucial. There is emerging evidence to support investigations such as serum N-terminal B-type natriuretic peptide levels, as well as cardiac magnetic resonance imaging as adjuncts to the clinical diagnosis. In the future, these may reduce the necessity for invasive methods, such as endomyocardial biopsy, which remain the gold standard. Management generally includes supportive care, consisting of cardiac failure medical management, with the potential for mechanical support and cardiac transplantation. Treatments aimed at immunosuppression remain controversial. The paediatrics literature is extremely limited with no conclusive evidence to support or refute these strategies. All these summarised in this article and the listed current literature showed that there is no consensus regarding aetiology, clinical presentation, diagnosis, and management of myocarditis in pediatric patients.
Collapse
Affiliation(s)
- Ramush Bejiqi
- Medical School, University of Gjakova, Gjakova, Kosovo.,Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Ragip Retkoceri
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Arlinda Maloku
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Aferdita Mustafa
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Hana Bejiqi
- Main Center of Family Medicine, Prishtina, Kosovo
| | - Rinor Bejiqi
- Medical School, University of Prishtina, Prishtina, Kosovo
| |
Collapse
|
25
|
Affiliation(s)
- Giorgio Gallinella
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| |
Collapse
|
26
|
Abstract
This review focuses on the identification, evaluation, management, and stabilization of a variety of acquired cardiac conditions, such as cardiomyopathies, inflammatory cardiac disease, and Kawasaki disease, which commonly require care in the pediatric intensive care unit (PICU). Pediatric cardiomyopathies comprise a spectrum of acquired or congenital myocardial diseases in which there are abnormalities of cardiac size and ventricular wall thickness, along with ventricular performance. The inflammatory diseases of the heart include acute myocarditis and pericarditis. Cardiac sequelae of Kawasaki disease resemble a self-limited vasculitis, but in rare instances may present with hemodynamic instability requiring vasopressor support. Care in the PICU affords both monitoring and management opportunities. [Pediatr Ann. 2018;47(7):e280-e285.].
Collapse
|
27
|
Fadl S, Wåhlander H, Fall K, Cao Y, Sunnegårdh J. The highest mortality rates in childhood dilated cardiomyopathy occur during the first year after diagnosis. Acta Paediatr 2018; 107:672-677. [PMID: 29224255 PMCID: PMC5887975 DOI: 10.1111/apa.14183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 09/15/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
Aim The aim of the study was to assess the incidence, mortality and morbidity of dilated cardiomyopathy (DCM) and noncompaction of the left ventricle (LVNC) in Swedish children. Methods We reviewed hospital records of all children with dilated cardiomyopathy (DCM) or left ventricular noncompaction cardiomyopathy (LVNC) up to the age of 18 in the healthcare region of western Sweden from 1991 to 2015. Results In total, 69 cases (61% males) were identified. The combined incidence of DCM and LVNC was 0.77 (95% CI 0.59‐0.96) per 100 000 person years. Children were divided into six groups, and their outcomes were analysed depending on their aetiology. Idiopathic DCM was reported in 43%, and familial dilated and left ventricular noncompaction aetiology was present in 32%. DCM due to various diseases occurred in 8%. DCM associated with neuromuscular diseases was present in 16%. The overall risk of death or receiving transplants in children with idiopathic and familial DCM was 30% over the study period, and 21% died in the first year after diagnosis. Conclusion The combined incidence of DCM and LVNC was similar to previous reports. Most children with idiopathic DCM presented during infancy, and mortality was highest during the first year after diagnosis.
Collapse
Affiliation(s)
- Shalan Fadl
- Department of Paediatrics; Örebro University Hospital; Örebro Sweden
| | - Håkan Wåhlander
- The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Institution of Clinical Sciences; Gothenburg University; Gothenburg Sweden
| | - Katja Fall
- Clinical Epidemiology and Biostatistics; School of Medical Sciences; Örebro University; Örebro Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics; School of Medical Sciences; Örebro University; Örebro Sweden
- Unit of Biostatistics; Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
| | - Jan Sunnegårdh
- The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Institution of Clinical Sciences; Gothenburg University; Gothenburg Sweden
| |
Collapse
|
28
|
Fulminant viral myocarditis treated by interferon-beta in a child. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
29
|
Miocarditis en Pediatría. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
30
|
Massin M, Crochelet AS, Jacquemart C. Acute Myocarditis With Very High Troponin but No Ventricular Dysfunction. Clin Pediatr (Phila) 2017; 56:582-583. [PMID: 27356633 DOI: 10.1177/0009922816656626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Martial Massin
- 1 Queen Fabiola Children's University Hospital, Free University of Brussels ULB, Brussels, Belgium
| | - Anne-Sophie Crochelet
- 1 Queen Fabiola Children's University Hospital, Free University of Brussels ULB, Brussels, Belgium
| | - Caroline Jacquemart
- 1 Queen Fabiola Children's University Hospital, Free University of Brussels ULB, Brussels, Belgium
| |
Collapse
|
31
|
Abstract
Parvovirus B19 (B19V) and human bocavirus 1 (HBoV1), members of the large Parvoviridae family, are human pathogens responsible for a variety of diseases. For B19V in particular, host features determine disease manifestations. These viruses are prevalent worldwide and are culturable in vitro, and serological and molecular assays are available but require careful interpretation of results. Additional human parvoviruses, including HBoV2 to -4, human parvovirus 4 (PARV4), and human bufavirus (BuV) are also reviewed. The full spectrum of parvovirus disease in humans has yet to be established. Candidate recombinant B19V vaccines have been developed but may not be commercially feasible. We review relevant features of the molecular and cellular biology of these viruses, and the human immune response that they elicit, which have allowed a deep understanding of pathophysiology.
Collapse
Affiliation(s)
- Jianming Qiu
- Department of Microbiology, Molecular Genetics and Immunology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
32
|
Casadonte JR, Mazwi ML, Gambetta KE, Palac HL, McBride ME, Eltayeb OM, Monge MC, Backer CL, Costello JM. Risk Factors for Cardiac Arrest or Mechanical Circulatory Support in Children with Fulminant Myocarditis. Pediatr Cardiol 2017; 38:128-134. [PMID: 27826709 DOI: 10.1007/s00246-016-1493-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/25/2016] [Indexed: 11/28/2022]
Abstract
In children with fulminant myocarditis (FM), we sought to describe presenting characteristics and clinical outcomes, and identify risk factors for cardiac arrest and mechanical circulatory support (MCS). A retrospective review of patients with FM admitted at our institution between January 1, 2004, and June 31, 2015, was performed. We compared characteristics and outcomes of FM patients who received cardiopulmonary resuscitation (CPR) and/or were placed on MCS (CPR/MCS group) to those who did not develop these outcomes (Control group). There were 28 patients who met criteria for FM. Median age was 1.2 years (1 day-17 years). Recovery of myocardial function occurred in 13 patients (46%); 6 (21%) had chronic ventricular dysfunction, 6 (21%) underwent heart transplantation, and 3 (11%) died prior to hospital discharge (including one death following heart transplant). Of the 28 FM patients, 13 (46%) developed cardiac arrest (n = 11) and/or received MCS (n = 8). When compared to controls, patients in the CPR/MCS group had a higher peak b-type natriuretic peptide (BNP) levels (p = 0.03) and peak inotropic scores (p = 0.02). No significant differences were found between groups in demographics; chest radiograph, electrocardiogram, or echocardiogram findings; or initial laboratory values including BNP, troponin, C-reactive protein, lactate, and creatinine (p > 0.05 for all). Children with FM are at high risk of cardiovascular collapse leading to the use of CPR or MCS. Aside from peak BNP levels and inotropic scores, the most presenting characteristics were not helpful for predicting these outcomes. FM patients should ideally receive care in centers that provide emergent MCS.
Collapse
Affiliation(s)
- Joseph R Casadonte
- Division of Cardiology, Regenstein Cardiac Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL, 60611-2605, USA
| | - Mjaye L Mazwi
- Division of Cardiology, Regenstein Cardiac Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL, 60611-2605, USA.,Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katheryn E Gambetta
- Division of Cardiology, Regenstein Cardiac Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL, 60611-2605, USA
| | - Hannah L Palac
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary E McBride
- Division of Cardiology, Regenstein Cardiac Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL, 60611-2605, USA.,Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Osama M Eltayeb
- Division of Cardiothoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael C Monge
- Division of Cardiothoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carl L Backer
- Division of Cardiothoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John M Costello
- Division of Cardiology, Regenstein Cardiac Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL, 60611-2605, USA. .,Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
33
|
Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, Francis GS, Lenihan D, Lewis EF, McNamara DM, Pahl E, Vasan RS, Ramasubbu K, Rasmusson K, Towbin JA, Yancy C. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e579-e646. [PMID: 27832612 DOI: 10.1161/cir.0000000000000455] [Citation(s) in RCA: 436] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
34
|
Myocarditis in Paediatric Patients: Unveiling the Progression to Dilated Cardiomyopathy and Heart Failure. J Cardiovasc Dev Dis 2016; 3:jcdd3040031. [PMID: 29367574 PMCID: PMC5715726 DOI: 10.3390/jcdd3040031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 12/15/2022] Open
Abstract
Myocarditis is a challenging and potentially life-threatening disease associated with high morbidity in some paediatric patients, due to its ability to present as an acute and fulminant disease and to ultimately progress to dilated cardiomyopathy. It has been described as an inflammatory disease of the myocardium caused by diverse aetiologies. Viral infection is the most frequent cause of myocarditis in developed countries, but bacterial and protozoal infections or drug hypersensitivity may also be causative agents. The prompt diagnosis in paediatric patients is difficult, as the spectrum of clinical manifestation can range from no myocardial dysfunction to sudden cardiac death. Recent studies on myocarditis pathogenesis have revealed a triphasic nature of this disease, which influences the diagnostic and therapeutic strategies to adopt in each patient. Endomyocardial biopsy remains the gold standard for diagnosing myocarditis, and several non-invasive diagnostic tools can be used to support the diagnosis. Intravenous immunoglobulin has become part of routine practice in the treatment of myocarditis in paediatric patients at many centres, but its true effect on the cardiac function has been the target of many studies. The aim of this review is to approach the recently discovered facets of paediatric myocarditis regarding its progression to dilated cardiomyopathy.
Collapse
|
35
|
Verdonschot J, Hazebroek M, Merken J, Debing Y, Dennert R, Brunner-La Rocca HP, Heymans S. Relevance of cardiac parvovirus B19 in myocarditis and dilated cardiomyopathy: review of the literature. Eur J Heart Fail 2016; 18:1430-1441. [PMID: 27748022 DOI: 10.1002/ejhf.665] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 12/24/2022] Open
Abstract
Over the last decade, parvovirus B19 (B19V) has frequently been linked to the pathogenesis of myocarditis (MC) and its progression towards dilated cardiomyopathy (DCM). The exact role of the presence of B19V and its load remains controversial, as this virus is also found in the heart of healthy subjects. Moreover, the prognostic relevance of B19V prevalence in endomyocardial biopsies still remains unclear. As a result, it is unclear whether the presence of B19V should be treated. This review provides an overview of recent literature investigating the presence of B19V and its pathophysiological relevance in MC and DCM, as well as in normal hearts. In brief, no difference in B19V prevalence is observed between MC/DCM and healthy control hearts. Therefore, the question remains open whether and how cardiac B19V may be of pathogenetic importance. Findings suggest that B19V is aetiologically relevant either in the presence of other cardiotropic viruses, or when B19V load is high and/or actively replicating, which both may maintain myocardial (low-grade) inflammation. Therefore, future studies should focus on the prognostic relevance of the viral load, replicative status and virus co-infections. In addition, the immunogenetic background of MC/DCM patients that makes them susceptible to develop heart failure upon presence of B19V should be more thoroughly investigated.
Collapse
Affiliation(s)
- Job Verdonschot
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| | - Mark Hazebroek
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| | - Jort Merken
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| | - Yannick Debing
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| | - Robert Dennert
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| | | | - Stephane Heymans
- Department of Cardiology, CARIM, Maastricht University Medical Centre, the Netherlands
| |
Collapse
|
36
|
The Impact of Specific Viruses on Clinical Outcome in Children Presenting with Acute Heart Failure. Int J Mol Sci 2016; 17:486. [PMID: 27043551 PMCID: PMC4848942 DOI: 10.3390/ijms17040486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/14/2016] [Accepted: 03/28/2016] [Indexed: 11/17/2022] Open
Abstract
The presence and type of viral genomes have been suggested as the main etiology for inflammatory dilated cardiomyopathy. Information on the clinical implication of this finding in a large population of children is lacking. We evaluated the prevalence, type, and clinical impact of specific viral genomes in endomyocardial biopsies (EMB) collected between 2001 and 2013 among 63 children admitted to our hospital for acute heart failure (median age 2.8 years). Viral genome was searched by polymerase chain reaction (PCR). Patients underwent a complete two-dimensional echocardiographic examination at hospital admission and at discharge and were followed-up for 10 years. Twenty-seven adverse events (7 deaths and 20 cardiac transplantations) occurred during the follow-up. Viral genome was amplified in 19/63 biopsies (35%); PVB19 was the most commonly isolated virus. Presence of specific viral genome was associated with a significant recovery in ejection fraction, compared to patients without viral evidence (p < 0.05). In Cox-regression analysis, higher survival rate was related to virus-positive biopsies (p < 0.05). When comparing long-term prognosis among different viral groups, a trend towards better prognosis was observed in the presence of isolated Parvovirus B19 (PVB19) (p = 0.07). In our series, presence of a virus-positive EMB (mainly PVB19) was associated with improvement over time in cardiac function and better long-term prognosis.
Collapse
|
37
|
Vigneswaran TV, Brown JR, Breuer J, Burch M. Parvovirus B19 myocarditis in children: an observational study. Arch Dis Child 2016; 101:177-80. [PMID: 26613943 DOI: 10.1136/archdischild-2014-308080] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 11/04/2015] [Indexed: 11/04/2022]
Abstract
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.
Collapse
Affiliation(s)
- Trisha V Vigneswaran
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Julianne R Brown
- Departments of Microbiology, Virology and Infection Prevention and Control, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London, London, UK
| | - Judith Breuer
- Departments of Microbiology, Virology and Infection Prevention and Control, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK UCL Division of Infection and Immunity, University College London, London, UK
| | - Michael Burch
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
38
|
Luo Y, Qiu J. Human parvovirus B19: a mechanistic overview of infection and DNA replication. Future Virol 2015; 10:155-167. [PMID: 26097496 DOI: 10.2217/fvl.14.103] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Human parvovirus B19 (B19V) is a human pathogen that belongs to genus Erythroparvovirus of the Parvoviridae family, which is composed of a group of small DNA viruses with a linear single-stranded DNA genome. B19V mainly infects human erythroid progenitor cells and causes mild to severe hematological disorders in patients. However, recent clinical studies indicate that B19V also infects nonerythroid lineage cells, such as myocardial endothelial cells, and may be associated with other disease outcomes. Several cell culture systems, including permissive and semipermissive erythroid lineage cells, nonpermissive human embryonic kidney 293 cells and recently reported myocardial endothelial cells, have been used to study the mechanisms underlying B19V infection and B19V DNA replication. This review aims to summarize recent advances in B19V studies with a focus on the mechanisms of B19V tropism specific to different cell types and the cellular pathways involved in B19V DNA replication including cellular signaling transduction and cell cycle arrest.
Collapse
Affiliation(s)
- Yong Luo
- Department of Microbiology, Molecular Genetics & Immunology, University of Kansas Medical Center, Mail Stop 3029, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jianming Qiu
- Department of Microbiology, Molecular Genetics & Immunology, University of Kansas Medical Center, Mail Stop 3029, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| |
Collapse
|
39
|
Affiliation(s)
- Charles E. Canter
- From the Division of Pediatric Cardiology, Department of Pediatrics, Washington University, St. Louis, MO
| | - Kathleen E. Simpson
- From the Division of Pediatric Cardiology, Department of Pediatrics, Washington University, St. Louis, MO
| |
Collapse
|
40
|
Abstract
Myocarditis is most often caused by a viral infection. Less common causes include other infectious agents and autoimmune diseases. Fulminant myocarditis is an unusual complication with a rapidly progressive course resulting in severe heart failure and cardiogenic shock. Fulminant myocarditis should be treated with full supportive care, using aggressive pharmacologic therapy and mechanical circulatory support, because significant improvement in left ventricular function will often occur. Cardiac transplantation is required in a small minority of patients. Cardiac magnetic resonance imaging is becoming a frequently used modality to aid in the diagnosis of myocarditis.
Collapse
Affiliation(s)
- Fredric Ginsberg
- Division of Cardiovascular Medicine, Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA.
| | | |
Collapse
|
41
|
Abstract
We report a case of an immunocompetent child who developed parvovirus B19 infection complicated by autoinflammatory disease with myocarditis, tamponade and macrophage activation syndrome. He recovered with immunotherapy including prednisone, immunoglobulins, cyclosporin and anakinra (anti-interleukin-1). The report shows that parvovirus can provoke severe systemic inflammation with acute heart injury and that anti-interleukin-1 might be considered in such parvovirus-related inflammation.
Collapse
|
42
|
Lindenburg ITM, van Klink JM, Smits-Wintjens VEHJ, van Kamp IL, Oepkes D, Lopriore E. Long-term neurodevelopmental and cardiovascular outcome after intrauterine transfusions for fetal anaemia: a review. Prenat Diagn 2013; 33:815-22. [DOI: 10.1002/pd.4152] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/31/2013] [Accepted: 05/01/2013] [Indexed: 11/08/2022]
Affiliation(s)
| | - Jeanine M. van Klink
- Division of Neonatology, Department of Pediatrics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Inge L. van Kamp
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | - Dick Oepkes
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics; Leiden University Medical Center; Leiden The Netherlands
| |
Collapse
|