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Lee S, Lee J, Cho SH, Roh G, Park HJ, Lee YJ, Jeon HE, Lee YS, Bae SH, Youn SB, Cho Y, Oh A, Ha D, Lee SY, Choi EJ, Cho S, Lee S, Kim DH, Kang MH, Yoon MS, Lim BK, Nam JH. Assessing the impact of mRNA vaccination in chronic inflammatory murine model. NPJ Vaccines 2024; 9:34. [PMID: 38360752 PMCID: PMC10869740 DOI: 10.1038/s41541-024-00825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/01/2024] [Indexed: 02/17/2024] Open
Abstract
The implications of administration of mRNA vaccines to individuals with chronic inflammatory diseases, including myocarditis, rheumatoid arthritis (RA), and inflammatory bowel disease (IBD), are unclear. We investigated mRNA vaccine effects in a chronic inflammation mouse model implanted with an LPS pump, focusing on toxicity and immunogenicity. Under chronic inflammation, mRNA vaccines exacerbated cardiac damage and myocarditis, inducing mild heart inflammation with heightened pro-inflammatory cytokine production and inflammatory cell infiltration in the heart. Concurrently, significant muscle damage occurred, with disturbances in mitochondrial fusion and fission factors signaling impaired muscle repair. However, chronic inflammation did not adversely affect muscles at the vaccination site or humoral immune responses; nevertheless, it partially reduced the cell-mediated immune response, particularly T-cell activation. These findings underscore the importance of addressing mRNA vaccine toxicity and immunogenicity in the context of chronic inflammation, ensuring their safe and effective utilization, particularly among vulnerable populations with immune-mediated inflammatory diseases.
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Affiliation(s)
- Seonghyun Lee
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Jisun Lee
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Sun-Hee Cho
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, 21999, Republic of Korea
| | - Gahyun Roh
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Hyo-Jung Park
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - You-Jeung Lee
- Department of Biomedical Science, Jungwon University, Goesan-gun, Chungbuk, 28024, Republic of Korea
| | - Ha-Eun Jeon
- Department of Biomedical Science, Jungwon University, Goesan-gun, Chungbuk, 28024, Republic of Korea
| | - Yu-Sun Lee
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Seo-Hyeon Bae
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Sue Bean Youn
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Youngran Cho
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Ayoung Oh
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Dahyeon Ha
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Soo-Yeon Lee
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Eun-Jin Choi
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Seongje Cho
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Sowon Lee
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
| | - Do-Hyung Kim
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- SML Biopharm, Gwangmyeong, 14353, Republic of Korea
| | - Min-Ho Kang
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea
- Department of Biomedical-Chemical Engineering, The Catholic University of Korea, 43 Jibong-ro, Bucheon-si, Gyeonggi-do, 14662, Republic of Korea
| | - Mee-Sup Yoon
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, 21999, Republic of Korea.
- Department of Molecular Medicine, College of Medicine, Gachon University, Incheon, 21999, Republic of Korea.
- Lee Gil Ya Cancer and Diabetes Institute, Incheon, 21999, Republic of Korea.
| | - Byung-Kwan Lim
- Department of Biomedical Science, Jungwon University, Goesan-gun, Chungbuk, 28024, Republic of Korea.
| | - Jae-Hwan Nam
- Department of Medical and Biological Sciences, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea.
- BK21 four Department of Biotechnology, The Catholic University of Korea, Gyeonggi-do, Bucheon, Republic of Korea.
- SML Biopharm, Gwangmyeong, 14353, Republic of Korea.
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2
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He W, Zhou L, Xu K, Li H, Wang JJ, Chen C, Wang D. Immunopathogenesis and immunomodulatory therapy for myocarditis. SCIENCE CHINA. LIFE SCIENCES 2023; 66:2112-2137. [PMID: 37002488 PMCID: PMC10066028 DOI: 10.1007/s11427-022-2273-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/16/2023] [Indexed: 04/03/2023]
Abstract
Myocarditis is an inflammatory cardiac disease characterized by the destruction of myocardial cells, infiltration of interstitial inflammatory cells, and fibrosis, and is becoming a major public health concern. The aetiology of myocarditis continues to broaden as new pathogens and drugs emerge. The relationship between immune checkpoint inhibitors, severe acute respiratory syndrome coronavirus 2, vaccines against coronavirus disease-2019, and myocarditis has attracted increased attention. Immunopathological processes play an important role in the different phases of myocarditis, affecting disease occurrence, development, and prognosis. Excessive immune activation can induce severe myocardial injury and lead to fulminant myocarditis, whereas chronic inflammation can lead to cardiac remodelling and inflammatory dilated cardiomyopathy. The use of immunosuppressive treatments, particularly cytotoxic agents, for myocarditis, remains controversial. While reasonable and effective immunomodulatory therapy is the general trend. This review focuses on the current understanding of the aetiology and immunopathogenesis of myocarditis and offers new perspectives on immunomodulatory therapies.
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Affiliation(s)
- Wu He
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ling Zhou
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ke Xu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Huihui Li
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - James Jiqi Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
| | - DaoWen Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
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3
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Grzechocińska J, Tymińska A, Giordani AS, Wysińska J, Ostrowska E, Baritussio A, Caforio ALP, Grabowski M, Marcolongo R, Ozierański K. Immunosuppressive Therapy of Biopsy-Proven, Virus-Negative, Autoimmune/Immune-Mediated Myocarditis-Focus on Azathioprine: A Review of Existing Evidence and Future Perspectives. BIOLOGY 2023; 12:356. [PMID: 36979048 PMCID: PMC10044979 DOI: 10.3390/biology12030356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023]
Abstract
The use of immunosuppressive therapy (IT) in biopsy-proven, autoimmune/immune-mediated (AI), virus-negative myocarditis has become the standard of care. In particular, according to recent guidelines, azathioprine (AZA), in association with steroids, is a cornerstone of first-line therapy regimens. IT may have a crucial impact on the natural history of AI myocarditis, preventing its progression to end-stage heart failure, cardiovascular death, or heart transplantation, provided that strict appropriateness and safety criteria are observed. In particular, AZA treatment for AI virus-negative myocarditis requires the consideration of some crucial aspects regarding its pharmacokinetics and pharmacodynamics, as well as a high index of suspicion to detect its overt and/or subclinical side effects. Importantly, besides a tight teamwork with a clinical immunologist/immuno-rheumatologist, before starting IT, it is also necessary to carry out a careful "safety check-list" in order to rule out possible contraindications to IT and minimize patient's risk. The aim of this review is to describe the pharmacological properties of AZA, as well as to discuss practical aspects of its clinical use, in the light of existing evidence, with particular regard to the new field of cardioimmunology.
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Affiliation(s)
- Justyna Grzechocińska
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
| | - Agata Tymińska
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
| | - Andrea Silvio Giordani
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35-100 Padova, Italy
| | - Julia Wysińska
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
| | - Ewa Ostrowska
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
| | - Anna Baritussio
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35-100 Padova, Italy
| | - Alida Linda Patrizia Caforio
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35-100 Padova, Italy
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
| | - Renzo Marcolongo
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35-100 Padova, Italy
| | - Krzysztof Ozierański
- First Department of Cardiology, Medical University of Warsaw, 1a Banacha St., 02-097 Warsaw, Poland
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4
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Immunoglobulin free light chains as an inflammatory biomarker of heart failure with myocarditis. Clin Immunol 2020; 217:108455. [PMID: 32479987 DOI: 10.1016/j.clim.2020.108455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND In this study, we measured immunoglobulin free light chains (FLC), a biomarker of inflammation in the sera of patients with heart failure due to myocarditis. METHODS FLC kappa and FLC lambda were assayed in stored serum samples from patients with heart failure with myocarditis from the US myocarditis treatment trial by a competitive-inhibition multiplex Luminex® assay. RESULTS The median concentration of circulating FLC kappa/lambda ratio was significantly lower in the sera from patients with heart failure with myocarditis than in healthy controls, and FLC kappa/lambda ratio had good diagnostic ability for identification of heart failure with myocarditis. Further, FLC kappa/lambda ratio was an independent prognostic factor for overall survival, and allowed creation of three prognostic groups by combining with N-terminal pro-B-type natriuretic peptide. CONCLUSIONS This study suggests that FLC kappa/lambda ratio is a promising biomarker of heart failure with myocarditis.
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5
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Ammirati E, Veronese G, Cipriani M, Moroni F, Garascia A, Brambatti M, Adler ED, Frigerio M. Acute and Fulminant Myocarditis: a Pragmatic Clinical Approach to Diagnosis and Treatment. Curr Cardiol Rep 2018; 20:114. [PMID: 30259175 DOI: 10.1007/s11886-018-1054-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To review the clinical features of acute myocarditis, including its fulminant presentation, and present a pragmatic approach to the diagnosis and treatment, considering indications of American and European Scientific Statements and recent data derived by large contemporary registries. RECENT FINDINGS Patients presenting with acute uncomplicated myocarditis (i.e., without left ventricular dysfunction, heart failure, or ventricular arrhythmias) have a favorable short- and long-term prognosis: these findings do not support the indication to endomyocardial biopsy in this clinical scenario. Conversely, patients with complicated presentations, especially those with fulminant myocarditis, require an aggressive and comprehensive management, including endomyocardial biopsy and availability of advanced therapies for circulatory support. Although several immunomodulatory or immunosuppressive therapies have been studied and are actually prescribed in the real-world practice, their effectiveness has not been clearly demonstrated. Patients with specific histological subtypes of acute myocarditis (i.e., giant cell and eosinophilic myocarditis) or those affected by sarcoidosis or systemic autoimmune disorders seem to benefit most from immunosuppression. On the other hand, no clear evidence supports the use of immunosuppressive agents in patients with lymphocytic acute myocarditis, even though small series suggest a potential benefit. Acute myocarditis is a heterogeneous condition with distinct pathophysiological pathways. Further research is mandatory to identify factors and mechanisms that may trigger/maintain or counteract/repair the myocardial damage, in order to provide a rational for future evidence-based treatment of patients affected by this condition.
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Affiliation(s)
- Enrico Ammirati
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.
| | - Giacomo Veronese
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Manlio Cipriani
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | | | - Andrea Garascia
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Maria Frigerio
- "De Gasperis" Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
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6
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Miteva K, Pappritz K, El-Shafeey M, Dong F, Ringe J, Tschöpe C, Van Linthout S. Mesenchymal Stromal Cells Modulate Monocytes Trafficking in Coxsackievirus B3-Induced Myocarditis. Stem Cells Transl Med 2017; 6:1249-1261. [PMID: 28186704 PMCID: PMC5442851 DOI: 10.1002/sctm.16-0353] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/07/2016] [Indexed: 12/16/2022] Open
Abstract
Mesenchymal stromal cell (MSC) application in Coxsackievirus B3 (CVB3)‐induced myocarditis reduces myocardial inflammation and fibrosis, exerts prominent extra‐cardiac immunomodulation, and improves heart function. Although the abovementioned findings demonstrate the benefit of MSC application, the mechanism of the MSC immunomodulatory effects leading to a final cardioprotective outcome in viral myocarditis remains poorly understood. Monocytes are known to be a trigger of myocardial tissue inflammation. The present study aims at investigating the direct effect of MSC on the mobilization and trafficking of monocytes to the heart in CVB3‐induced myocarditis. One day post CVB3 infection, C57BL/6 mice were intravenously injected with 1 x 106 MSC and sacrificed 6 days later for molecular biology and flow cytometry analysis. MSC application reduced the severity of myocarditis, and heart and blood pro‐inflammatory Ly6Chigh and Ly6Cmiddle monocytes, while those were retained in the spleen. Anti‐inflammatory Ly6Clow monocytes increased in the blood, heart, and spleen of MSC‐treated CVB3 mice. CVB3 infection induced splenic myelopoiesis, while MSC application slightly diminished the spleen myelopoietic activity in CVB3 mice. Left ventricular (LV) mRNA expression of the chemokines monocyte chemotactic protein‐1 (MCP)−1, MCP‐3, CCL5, the adhesion molecules intercellular adhesion molecule‐1, vascular cell adhesion molecule‐1, the pro‐inflammatory cytokines interleukin‐6, interleukin‐12, tumor necrosis factor‐α, the pro‐fibrotic transforming growth factorβ1, and circulating MCP‐1 and MCP‐3 levels decreased in CVB3 MSC mice, while LV stromal cell‐derived factor‐1α RNA expression and systemic levels of fractalkine were increased in CVB3 MSC mice. MSC application in CVB3‐induced myocarditis modulates monocytes trafficking to the heart and could be a promising strategy for the resolution of cardiac inflammation and prevention of the disease progression. Stem Cells Translational Medicine2017;6:1249–1261
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Affiliation(s)
- Kapka Miteva
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany
| | - Kathleen Pappritz
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany
| | - Muhammad El-Shafeey
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Fengquan Dong
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Jochen Ringe
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany.,Laboratory for Tissue Engineering, Charité, University Medicine Berlin, Berlin, Germany
| | - Carsten Tschöpe
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany.,Department of Cardiology, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Sophie Van Linthout
- Berlin-Brandenburg Center for Regenerative Therapies, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany.,Department of Cardiology, Charité, University Medicine Berlin, Campus Virchow, Berlin, Germany
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7
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Sime TA, Powell LL, Schildt JC, Olson EJ. Parvoviral myocarditis in a 5-week-old Dachshund. J Vet Emerg Crit Care (San Antonio) 2015. [PMID: 26220397 DOI: 10.1111/vec.12347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe a case of myocarditis associated with naturally occurring canine parvovirus type 2 (CPV-2). CASE SUMMARY A 5-week-old male intact Dachshund dog presented for acute respiratory distress. Limited diagnostic tests prior to the dog experiencing cardiopulmonary arrest included a lateral thoracic radiograph, which indicated cardiomegaly and diffuse unstructured pulmonary infiltrate. Necropsy was performed and results identified a lymphoplasmacytic myocarditis with positive CPV-2 immunohistochemistry within the myocardium. UNIQUE INFORMATION PROVIDED This report describes the natural occurrence of CPV-2-associated myocarditis. In addition to highlighting this rare form of canine parvovirus, cardiomyopathy in survivors of the acute viral myocarditis phase is reviewed.
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Affiliation(s)
- Tara A Sime
- From the Department of Veterinary Clinical Sciences (Sime, Powell, Schildt), and the Department of Veterinary Population Medicine, Veterinary Diagnostic Laboratory (Olson), College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - Lisa L Powell
- From the Department of Veterinary Clinical Sciences (Sime, Powell, Schildt), and the Department of Veterinary Population Medicine, Veterinary Diagnostic Laboratory (Olson), College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - Julie C Schildt
- From the Department of Veterinary Clinical Sciences (Sime, Powell, Schildt), and the Department of Veterinary Population Medicine, Veterinary Diagnostic Laboratory (Olson), College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - Erik J Olson
- From the Department of Veterinary Clinical Sciences (Sime, Powell, Schildt), and the Department of Veterinary Population Medicine, Veterinary Diagnostic Laboratory (Olson), College of Veterinary Medicine, University of Minnesota, St. Paul, MN
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8
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Tiwari S, Reddy VB, Bhargava R, Raman J. Computational chemical imaging for cardiovascular pathology: chemical microscopic imaging accurately determines cardiac transplant rejection. PLoS One 2015; 10:e0125183. [PMID: 25932912 PMCID: PMC4416885 DOI: 10.1371/journal.pone.0125183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/10/2015] [Indexed: 02/06/2023] Open
Abstract
Rejection is a common problem after cardiac transplants leading to significant number of adverse events and deaths, particularly in the first year of transplantation. The gold standard to identify rejection is endomyocardial biopsy. This technique is complex, cumbersome and requires a lot of expertise in the correct interpretation of stained biopsy sections. Traditional histopathology cannot be used actively or quickly during cardiac interventions or surgery. Our objective was to develop a stain-less approach using an emerging technology, Fourier transform infrared (FT-IR) spectroscopic imaging to identify different components of cardiac tissue by their chemical and molecular basis aided by computer recognition, rather than by visual examination using optical microscopy. We studied this technique in assessment of cardiac transplant rejection to evaluate efficacy in an example of complex cardiovascular pathology. We recorded data from human cardiac transplant patients’ biopsies, used a Bayesian classification protocol and developed a visualization scheme to observe chemical differences without the need of stains or human supervision. Using receiver operating characteristic curves, we observed probabilities of detection greater than 95% for four out of five histological classes at 10% probability of false alarm at the cellular level while correctly identifying samples with the hallmarks of the immune response in all cases. The efficacy of manual examination can be significantly increased by observing the inherent biochemical changes in tissues, which enables us to achieve greater diagnostic confidence in an automated, label-free manner. We developed a computational pathology system that gives high contrast images and seems superior to traditional staining procedures. This study is a prelude to the development of real time in situ imaging systems, which can assist interventionists and surgeons actively during procedures.
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Affiliation(s)
- Saumya Tiwari
- Department of Bioengineering, Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana Champaign, Urbana, Illinois, 61801, United States of America
| | - Vijaya B. Reddy
- Department of Pathology, Rush University Medical Center, 1725 West Harrison St, Chicago, Illinois, 60612, United States of America
| | - Rohit Bhargava
- Department of Bioengineering, Chemistry, Mechanical Science and Engineering, Chemical and Biomolecular Engineering, Electrical and Computer Engineering, Beckman Institute for Advanced Science and Technology and University of Illinois Cancer Center, University of Illinois at Urbana-Champaign, Urbana, Illinois, 61801, United States of America
| | - Jaishankar Raman
- Cardiac Surgery, Advanced Heart Failure Transplantation & Mechanical Circulatory Support, Rush University Medical Center, 1725 West Harrison St, Chicago, Illinois, 60612, United States of America
- * E-mail:
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9
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Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, Jorde UP, Uriel N. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res 2014; 7:156-64. [PMID: 24420915 DOI: 10.1007/s12265-013-9521-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022]
Abstract
In fulminant myocarditis complicated by cardiogenic shock, early mechanical circulatory support (MCS) may prevent cardiomyopathy and death. We sought to examine the outcomes of patients with fulminant myocarditis supported with MCS. A retrospective review of patients with acute cardiogenic shock treated with MCS from 2007 to 2013 was conducted, and patients with a diagnosis of fulminant myocarditis were included in this series. At our center, 260 patients received MCS for acute cardiogenic shock, and 11 were implanted for fulminant myocarditis. Eight received the Centrimag biventricular assist device (BIVAD), and three received veno-arterial extracorporeal membrane oxygenator (VA ECMO), though 1 VA ECMO-supported patient was transitioned to BIVAD due to refractory shock. The mean acute support time was 14.7 ± 4.4 days. Two patients required long-term left ventricular assist devices and were further supported for 55 and 112 days. Eight patients recovered with a mean ejection fraction of 54 ± 7 %, and one was successfully transplanted. Eight patients survived to discharge (73 %) with mean follow-up: 292.6 ± 306.8 days. All three deaths were due to neurologic complications. MCS should be considered in patients with fulminant myocarditis complicated by shock. With aggressive medical therapy, early utilization of MCS carries promising outcomes.
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Affiliation(s)
- Kanika P Mody
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, 10032, USA
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10
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Abstract
BACKGROUND Myocarditis is defined as inflammation of the myocardium accompanied by myocellular necrosis. Experimental evidence suggests that autoimmune mechanisms follow viral infection, resulting in inflammation and necrosis in the myocardium. However, the use of corticosteroids as immunosuppressives for this condition remains controversial. OBJECTIVES The existing review was updated. The primary objective of this review is to assess the beneficial and harmful effects of treating acute or chronic viral myocarditis with corticosteroids. The secondary objective is to determine the best dose regimen. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2012) on The Cochrane Library, MEDLINE OVID (1946 to July Week 2, 2012), EMBASE OVID (1980 to Week 29, 2012), BIOSIS Previews (1969 to 20 July 2012), ISI Web of Science (1970 to 20th July, 2012), and LILACS (from its inception to 25 July, 2012) , Chinese Biomed Database, CNKI and WANFANG Databases (from their inception to 31 December 2012). We applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) of corticosteroids for viral myocarditis compared with no intervention, placebo, supportive therapy, antiviral agents therapy or conventional therapy, including trials of corticosteroids plus other treatment versus other treatment alone, irrespective of blinding, publication status, or language. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. Results were presented as risk ratios (RRs) and mean differences (MDs), both with 95% confidence intervals (CIs). MAIN RESULTS Eight RCTs (with 719 participants) were included in this update. The trials were small in size and methodological quality was poor. Viral detection was performed in 38% of participants, among whom 56% had positive results. Mortality between corticosteroids and control groups was non-significant (RR, 0.93, 95% CI 0.70 to 1.24). At 1 to 3 months follow-up, left ventricular ejection fraction (LVEF) was higher in the corticosteroids group compared to the control group (MD 7.36%, 95% CI 4.94 to 9.79), but there was substantial heterogeneity. Benefits were observed in LVEF in two trials with 200 children given corticosteroids (MD 9.00%, 95% CI 7.48 to 10.52). New York Heart Association (NYHA) class and left ventricular end-stage systole diameter (LVESD) were not affected. Creatine phosphokinase (CPK) (MD -104.00 U/L, 95% CI -115.18 to -92.82), Isoenzyme of creatine phosphate MB (CKMB) (MD 10.35 U/L, 95% CI 8.92 to 11.78), were reduced in the corticosteroids group compared to the control group, although the evidence is limited to small participant numbers. There were insufficient data on adverse events. AUTHORS' CONCLUSIONS For people diagnosed with viral myocarditis and low LVEF, corticosteroids do not reduce mortality. They may improve cardiac function but the trials were of low quality and small size so this finding must be regarded as uncertain. High-quality, large-scale RCTs should be careful designed to determine the role of corticosteroid treatment for viral myocarditis. Adverse events should also be carefully evaluated.
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Affiliation(s)
- Huai Sheng Chen
- Intensive Care Unit, Shenzhen People's Hospital, The Second Affiliated Hospital of Ji Nan University, 1017 Dong Men Bei Lu, Luo Hu District, Shenzhen City, Guangdong, China, 518020
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11
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Abstract
Acute myocarditis is an inflammatory disease of the heart muscle that may progress to dilated cardiomyopathy and chronic heart failure. A number of factors including the sex hormone testosterone, components of innate immunity, and profibrotic cytokines have been identified in animal models as important pathogenic mechanisms that increase inflammation and susceptibility to chronic dilated cardiomyopathy. The clinical presentation of acute myocarditis is non-specific and mimics more common causes of heart failure and arrhythmias. Suspected myocarditis is currently confirmed using advanced non-invasive imaging and histopathologic examination of heart tissue. However, the diverse presentations of myocarditis and the lack of widely available, safe, and accurate non-invasive diagnostic tests remain major obstacles to early diagnosis and population based research. Recent advances in the understanding of disease pathogenesis described in this review should lead to more accurate diagnostic algorithms and non-invasive tests.
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Affiliation(s)
- Chantal Elamm
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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12
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Berry CM, Hertzog PJ, Mangan NE. Interferons as biomarkers and effectors: lessons learned from animal models. Biomark Med 2012; 6:159-76. [PMID: 22448790 DOI: 10.2217/bmm.12.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Interferons (IFNs) comprise type I, II and III families with multiple subtypes. Via transcription of IFN-stimulated genes (ISGs), IFNs can exert multiple biological effects on the cell. In infectious and chronic inflammatory diseases, the IFNs and their ISG sets can be potentially utilized as biomarkers of disease outcome. Animal models allow investigations into disease pathogenesis and gene knockout models have proved cause and effect relationships of molecules related to the IFN response. Sets of IFN subtypes and their ISG products provide immunological signature patterns for different viral and other diseases. In this article, we give an overview of IFNs in several virus infection models and autoimmune diseases of medical relevance. Lessons learned from animal models inform us of IFN system parameters as indicators of disease outcome and whether clinical research is warranted. Moreover, validated IFN biomarkers for prognosis enhance our understanding of therapeutic and vaccine development.
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Affiliation(s)
- Cassandra M Berry
- Centre for Innate Immunity & Infectious Diseases, Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia.
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13
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Nair JR, Somauroo JD, Over KE. Myopericarditis in giant cell arteritis: case report of diagnostic dilemma and review of literature. BMJ Case Rep 2012; 2012:bcr.12.2011.5469. [PMID: 22744263 DOI: 10.1136/bcr.12.2011.5469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Giant cell arteritis (GCA), also known as granulomatous arteritis is a systemic vasculitis mainly affecting extra cranial branches of carotid arteries. It can rarely affect other vascular beds causing thoracic aorta aneurysm, dissection and rarely cause myocardial infarction through coronary arteritis. It can cause considerable diagnostic dilemma due to varied clinical presentations. The authors report an illustrative case of a 70-year-old woman with GCA who developed symptoms suggestive of acute myocardial infarction with chest pain, localised ST-T changes and echocardiographic left ventricular dysfunction. However, cardiac troponin T biomarkers and coronary angiography were normal. Her symptoms subsided with steroid treatment. Cardiac symptoms at first presentation of GCA are unusual.
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14
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Matsumori A, Shimada T, Hattori H, Shimada M, Mason JW. Autoantibodies against cardiac troponin I in patients presenting with myocarditis. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.cvdpc.2011.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Barry SP, Townsend PA. What causes a broken heart--molecular insights into heart failure. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2011; 284:113-79. [PMID: 20875630 DOI: 10.1016/s1937-6448(10)84003-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Our understanding of the molecular processes which regulate cardiac function has grown immeasurably in recent years. Even with the advent of β-blockers, angiotensin inhibitors and calcium modulating agents, heart failure (HF) still remains a seriously debilitating and life-threatening condition. Here, we review the molecular changes which occur in the heart in response to increased load and the pathways which control cardiac hypertrophy, calcium homeostasis, and immune activation during HF. These can occur as a result of genetic mutation in the case of hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) or as a result of ischemic or hypertensive heart disease. In the majority of cases, calcineurin and CaMK respond to dysregulated calcium signaling and adrenergic drive is increased, each of which has a role to play in controlling blood pressure, heart rate, and left ventricular function. Many major pathways for pathological remodeling converge on a set of transcriptional regulators such as myocyte enhancer factor 2 (MEF2), nuclear factors of activated T cells (NFAT), and GATA4 and these are opposed by the action of the natriuretic peptides ANP and BNP. Epigenetic modification has emerged in recent years as a major influence cardiac physiology and histone acetyl transferases (HATs) and histone deacetylases (HDACs) are now known to both induce and antagonize hypertrophic growth. The newly emerging roles of microRNAs in regulating left ventricular dysfunction and fibrosis also has great potential for novel therapeutic intervention. Finally, we discuss the role of the immune system in mediating left ventricular dysfunction and fibrosis and ways this can be targeted in the setting of viral myocarditis.
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Affiliation(s)
- Seán P Barry
- Institute of Molecular Medicine, St. James's Hospital, Trinity College Dublin, Dublin 8, Ireland
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17
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Abstract
Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms in children and adults. Viral infection is the most common cause of myocarditis in developed countries, but other etiologies include bacterial and protozoal infections, toxins, drug reactions, autoimmune diseases, giant cell myocarditis, and sarcoidosis. Acute injury leads to myocyte damage, which in turn activates the innate and humeral immune system, leading to severe inflammation. In most patients, the immune reaction is eventually down-regulated and the myocardium recovers. In select cases, however, persistent myocardial inflammation leads to ongoing myocyte damage and relentless symptomatic heart failure or even death. The diagnosis is usually made based on clinical presentation and noninvasive imaging findings. Most patients respond well to standard heart failure therapy, although in severe cases, mechanical circulatory support or heart transplantation is indicated. Prognosis in acute myocarditis is generally good except in patients with giant cell myocarditis. Persistent, chronic myocarditis usually has a progressive course but may respond to immunosuppression.
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Affiliation(s)
- Lori A Blauwet
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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18
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Myocarditis and pericarditis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00046-0] [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: 11/22/2022] Open
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Cooper LT, Onuma OK, Sagar S, Oberg AL, Mahoney DW, Asmann YW, Liu P. Genomic and Proteomic Analysis of Myocarditis and Dilated Cardiomyopathy. Heart Fail Clin 2010; 6:75-85. [DOI: 10.1016/j.hfc.2009.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Friedrich MG, Sechtem U, Schulz-Menger J, Holmvang G, Alakija P, Cooper LT, White JA, Abdel-Aty H, Gutberlet M, Prasad S, Aletras A, Laissy JP, Paterson I, Filipchuk NG, Kumar A, Pauschinger M, Liu P. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol 2009; 53:1475-87. [PMID: 19389557 DOI: 10.1016/j.jacc.2009.02.007] [Citation(s) in RCA: 1639] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 01/31/2009] [Accepted: 02/03/2009] [Indexed: 02/06/2023]
Abstract
Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., "Lake Louise Criteria").
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Affiliation(s)
- Matthias G Friedrich
- Department of Cardiac Sciences and Radiology, Stephenson Cardiovascular MR Centre at the Libin Cardiovascular Institute of Alberta, Canada.
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21
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Esfandiarei M, McManus BM. Molecular biology and pathogenesis of viral myocarditis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2008; 3:127-55. [PMID: 18039131 DOI: 10.1146/annurev.pathmechdis.3.121806.151534] [Citation(s) in RCA: 273] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Myocarditis is a cardiac disease associated with inflammation and injury of the myocardium. Several viruses have been associated with myocarditis in humans. However, coxsackievirus B3 is still considered the dominant etiological agent. The observed pathology in viral myocarditis is a result of cooperation or teamwork between viral processes and host immune responses at various stages of disease. Both innate and adaptive immune responses are crucial determinants of the severity of myocardial damage, and contribute to the development of chronic myocarditis and dilated cardiomyopathy following acute viral myocarditis. Advances in genomics and proteomics, and in the use of informatics and biostatistics, are allowing unbiased initial evaluations that can be the basis for testable hypotheses about virus pathogenesis and new therapies.
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Affiliation(s)
- Mitra Esfandiarei
- The James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research, St. Paul's Hospital, Providence Health Care Research Institute, Vancouver, Canada.
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22
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Matsumori A, Shimada T, Chapman NM, Tracy SM, Mason JW. Myocarditis and heart failure associated with hepatitis C virus infection. J Card Fail 2006; 12:293-8. [PMID: 16679263 DOI: 10.1016/j.cardfail.2005.11.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Revised: 11/08/2005] [Accepted: 11/08/2005] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of study is to determine the prevalence of hepatitis C virus (HCV) infection and myocardial injury among patients enrolled in the Myocarditis Treatment Trial. HCV infection has recently been noted in patients with cardiomyopathies and myocarditis. However, prevalence of HCV infection in myocarditis and heart failure remains to be clarified. METHODS AND RESULTS Patients with heart failure up to 2 years in duration without a distinct cause were enrolled in the trial between 1986 and 1990. Frozen blood samples were available from 1355 among 2233 patients enrolled and examined for presence of anti-HCV antibodies, circulating cardiac troponins I and T, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Anti-HCV antibodies were identified in 59 of 1355 patients (4.4%). This higher prevalence of HCV infection than that observed in the general US population (1.8%), varied widely (0-15%) among the different medical centers and regions. The concentrations of circulating cardiac troponin (cTn) I were elevated in 17 of 56 patients (30%), and cTnT was detectable in 28 of 59 patients (48%) with HCV antibodies, suggesting the persistence of ongoing myocardial injury. The concentrations of NT-proBNP were elevated in 42 of 42 patients (100%) with HCV antibodies, (10,000 +/- 5860 pg/mL), a mean value significantly greater than in 1276 patients without HCV antibody (2508 +/- 160 pg/mL, P < .0001). CONCLUSION Anti-HCV antibodies were identifiable in sera stored for 13 to 17 years and were more prevalent in patients with myocarditis and HF than in the general population. In regions where its prevalence is high, HCV infection may be an important cause of myocarditis and HF. NT-proBNP is a more sensitive marker of myocardial injury than cardiac troponins in patients with heart failure from HCV myocarditis.
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Affiliation(s)
- Akira Matsumori
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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23
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Weinkauf J, Walia R, Berry GJ, Vagelos R, Faul JL. Lymphocytic Myocarditis After Lung Transplantation. J Heart Lung Transplant 2005; 24:1163-5. [PMID: 16102466 DOI: 10.1016/j.healun.2004.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Revised: 07/07/2004] [Accepted: 07/19/2004] [Indexed: 10/25/2022] Open
Abstract
This study reports the development of lymphocytic myocarditis in a bilateral lung allograft recipient. A 23-year-old woman developed congestive heart failure and severe left ventricular dysfunction 32 months after a bilateral lung allograft for cystic fibrosis. She had taken oral acyclovir for infectious mononucleosis that was diagnosed 11 months previously. Her viral load for Epstein-Barr virus (EBV) increased, and an echocardiogram revealed a left ventricular ejection fraction of 25% and endomyocardial biopsy revealed lymphocytic myocarditis. She received valacyclovir (1 g x 3 times daily) and made a full recovery 6 months later.
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Affiliation(s)
- Justin Weinkauf
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, California, USA
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24
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Reinders J, Parsonage W, Lange D, Potter JM, Plever S. Clozapine-related myocarditis and cardiomyopathy in an Australian metropolitan psychiatric service. Aust N Z J Psychiatry 2004; 38:915-22. [PMID: 15555025 DOI: 10.1080/j.1440-1614.2004.01481.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Myocarditis and cardiomyopathy are rarely reported complications of clozapine treatment. The incidence of clozapine-related myocarditis has been variably reported at between 0.03% and 0.19% of initiations and cardiomyopathy has been reported even less commonly. In our Brisbane-based service, nine of 94 patients initiated on clozapine over the previous 3 years appeared to have experienced myocarditis or cardiomyopathy. The unique co-location of our service with a major cardiothoracic hospital facilitated a review of identified cases to inform decisions regarding clozapine treatment and rechallenge in this service. METHOD Cases were identified by survey of psychiatric and cardiac medical staff at The Prince Charles Hospital and subjected to re-evaluation by a multidiscipline consensus panel. The panel compared cases to international reports and identified the clinical features that supported a diagnosis of clozapine-related myocarditis or cardiomyopathy. RESULTS This process resulted in the stratification of the nine cases into the following categories of diagnostic likelihood: three highly probable, three probable, and two possible cases of clozapine-related myocarditis, and one possible case of clozapine-related cardiomyopathy. Successful clozapine rechallenge/continuation was undertaken in two patients and the panel agreed that this was a viable future option for several other patients. CONCLUSIONS Findings of the panel review supported the initial clinical diagnoses. This confirmed that there was an apparent high incidence of clozapine-related myocarditis within this service, for which there was no clear reason. Mechanisms underlying clozapine-related myocarditis and cardiomyopathy, as well as successful clozapine continuation and rechallenge were considered, but definitive explanations remain unknown. This review highlighted the clinician's role in post-marketing drug surveillance to guide rational management of suspected adverse drug effects.
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Affiliation(s)
- Jonathan Reinders
- Department of Psychiatry, The Prince Charles Hospital Health Service District, Queensland, Australia.
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25
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Abstract
BACKGROUND Immunosuppressive therapy is reportedly ineffective in adults with acute myocarditis. AIMS To systematically review the impact of immunosuppressive therapy on the outcome of acute myocarditis in children. METHODS A literature search for articles published from 1984 to 2003 was conducted with the following keywords: myocarditis, dilated cardiomyopathy, and immunosuppression. The relevant studies were systematically reviewed and comparison of treatment effect was made by calculating the odds ratio (OR) and confidence interval (CI) using the exact method based on the exact discrete reference distribution. RESULTS Of the 1470 articles found, only nine studies were eligible. The odds for improvement with immunosuppression was between 4.33 (95% CI 0.52 to 52.23) and 2.7 (95% CI 0.59 to 14.21). Addition of a second immunosuppressive agent to prednisolone only proved effective in one randomised controlled trial (OR 0.09, 95% CI 0.01 to 0.52). Heterogeneity of these studies precluded pooled odds ratio. CONCLUSION Current data suggest that immunosuppressive therapy does not significantly improve outcomes in children with acute myocarditis and there is insufficient evidence for its routine use. However, statistical power to detect a significant difference in the treatment effect may be limited because of the small number of subjects. This, together with problems of diagnosis, varying treatment practices, and a relative lack of evidence based guidelines would support efforts for a large multicentre, randomised controlled trial to better define the role of immunosuppression in acute myocarditis.
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Affiliation(s)
- C P P Hia
- Department of Paediatrics, National University of Singapore, National University Hospital, Singapore
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26
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Abstract
The newest treatment strategies for pediatric myocarditis have evolved from an understanding of the pathophysiology of myocyte damage. Although the initial stages of viral myocarditis apparently result from the direct cytopathic effects on the atrial and ventricular myocardium, later stages of progressive decompensation result from immune-mediated myocyte destruction common to many forms of myocarditis. Despite advances in the understanding of the role of genetics, immunologic mechanisms, and infectious causes of myocarditis, supportive therapy continues to remain the cornerstone of treatment. Presently, therapies include supportive management with anticongestive agents, antiviral medications, and therapies that attempt to interrupt the immunologic cascade. Clinical studies have yet to provide convincing evidence that the use of immunosuppressants and gamma-globulin favorably alters the outcome for pediatric patients with acute myocarditis. Ventricular assist devices and heart transplantation remain as treatment options for all pediatric patients with severe myocarditis resistant to all other therapies. Although this review will focus on viral myocarditis, the supportive strategies and surgical treatment options apply to most forms of cardiomyopathy.
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Affiliation(s)
- Daniel Levi
- Department of Pediatrics, School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Kohno K, Aoyama N, Shimohama T, Yoshida M, Machida Y, Fukuda N, Aizaki T, Suzuki K, Kurosawa T, Izumi T. Resuscitation from fulminant myocarditis associated with refractory ventricular fibrillation. JAPANESE CIRCULATION JOURNAL 2000; 64:139-43. [PMID: 10716529 DOI: 10.1253/jcj.64.139] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Resuscitation was possible in a case of fulminant myocarditis with refractory ventricular fibrillation (Vf) using a percutaneous cardiopulmonary support system (PCPS). A 46-year old Japanese man suddenly experienced cardiopulmonary dysfunction shortly after the onset of flu symptoms, was promptly diagnosed as having fulminant myocarditis and PCPS was immediately initiated. On the second day in the hospital, refractory Vf occurred, which lasted for approximately 2h despite repeated efforts to terminate it. Finally, a large dose of steroids was administered. From the third day of hospitalization and onwards, the Vf disappeared totally. The patient completely recovered from such a serious state in 6 months. During the following 3 years, he has had no clinical symptoms of worsening. As in this case demonstrates, most myocarditis is curable and invasive measures are very helpful in rescuing patients from the fulminant type with refractory Vf.
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Affiliation(s)
- K Kohno
- Department of Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan.
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Mendes LA, Picard MH, Dec GW, Hartz VL, Palacios IF, Davidoff R. Ventricular remodeling in active myocarditis. Myocarditis Treatment Trial. Am Heart J 1999; 138:303-8. [PMID: 10426843 DOI: 10.1016/s0002-8703(99)70116-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Remodeling of the left ventricle with the development of a spherical cavity occurs in dilated cardiomyopathy and is associated with a poor long-term prognosis. The early effects of myocarditis on left ventricular geometry have not been previously described or correlated with clinical outcome. METHODS The baseline echocardiograms of 35 patients with biopsy-confirmed myocarditis were compared with 20 normal controls. Left ventricular end-diastolic volume, long axis length, and mid-cavity diameter were measured. The degree of sphericity was expressed as the ratio of the mid-cavity diameter to the long axis length. Left ventricular ejection fraction was assessed by radionuclide angiography. RESULTS In patients with myocarditis, mean left ventricular volume of 81 +/- 29 mL/m(2) was significantly greater than 50 +/- 8 mL/m(2) in controls (P =.001). Chamber dilatation occurred primarily along the mid-cavity diameter, which measured 5.3 +/- 0.8 cm in patients with myocarditis versus 4.2 +/- 0.4 cm in controls (P =.001). The degree of left ventricular sphericity in patients with myocarditis, 0.64 +/- 0.08, was significantly greater than that of controls, 0.54 +/- 0.04 (P =.001). When patients were stratified according to left ventricular volume, patients with increased left ventricular volume (>75 mL/m(2)) were associated with a more spherical chamber and lower left ventricular ejection fraction than patients with a more normal left ventricular volume (</=75 mL/m(2)). CONCLUSIONS Active myocarditis is associated with early left ventricular remodeling and the development of a spherical chamber. These changes correlate with ventricular dilatation and reduced left ventricular ejection fraction.
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston Medical Center, Boston, MA, USA
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Lee KJ, McCrindle BW, Bohn DJ, Wilson GJ, Taylor GP, Freedom RM, Smallhorn JF, Benson LN. Clinical outcomes of acute myocarditis in childhood. Heart 1999; 82:226-33. [PMID: 10409542 PMCID: PMC1729152 DOI: 10.1136/hrt.82.2.226] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe clinical outcomes of a paediatric population with histologically confirmed lymphocytic myocarditis. DESIGN A retrospective review between November 1984 and February 1998. SETTING A major paediatric tertiary care hospital. PATIENTS 36 patients with histologically confirmed lymphocytic myocarditis. MAIN OUTCOME MEASURES Survival, cardiac transplantation, recovery of ventricular function, and persistence of dysrhythmias. RESULTS Freedom from death or cardiac transplantation was 86% at one month and 79% after two years. Five deaths occurred within 72 hours of admission, and one late death at 1.9 years. Extracorporeal membrane oxygenation support was used in four patients, and three patients underwent heart replacement. 34 patients were treated with intravenous corticosteroids. In the survivor/non-cardiac transplantation group (n = 29), the median follow up was 19 months (range 1.2-131.6 months), and the median period for recovery of a left ventricular ejection fraction to > 55% was 2.8 months (range 0-28 months). The mean (SD) final left ventricular ejection and shortening fractions were 66 (9)% and 34 (8)%, respectively. Two patients had residual ventricular dysfunction. No patient required antiarrhythmic treatment. All survivors reported no cardiac symptoms or restrictions in physical activity. CONCLUSIONS Our experience documents good outcomes in paediatric patients presenting with acute heart failure secondary to acute lymphocytic myocarditis treated with immunosuppression. Excellent survival and recovery of ventricular function, with the absence of significant arrhythmias, continued cardiac medications, or restrictions in physical activity were the normal outcomes.
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Affiliation(s)
- K J Lee
- Division of Cardiology, Hospital for Sick Children, 555 University Avenue,Toronto, Ontario M5G 1X8, Canada
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Abstract
Myocarditis is the end result of a heterogeneous group of conditions which cause inflammation of the myocardium. The resulting myocardial dysfunction may be responsible for significant morbidity and reduced life expectancy of the survivors. The condition is difficult to diagnose and treatment is on the whole rather unsatisfactory. Further work is undoubtedly required to identify methods for early identification of the condition and to develop better therapies aimed at preventing progression to chronic heart failure.
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Affiliation(s)
- A Brodison
- Regional Cardiothoracic Department, Blackpool Victoria Hospital, U.K
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Hufnagel G, Pankuweit S, Maisch B. [Therapy of dilated cardiomyopathies with and without inflammation]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1998; 93:240-51. [PMID: 9594534 DOI: 10.1007/bf03044800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnosis of inflammatory dilated cardiomyopathy relies on the histological and immunohistological examination of endomyocardial biopsies. Only with the demonstration of the etiological agents in the myocardium specific therapy can be attempted. Whereas the spontaneous course of endemic myocarditis with little hemodynamic impairment is fair, the prognosis of symptomatic myocarditis and dilated cardiomyopathy is poor, with complete restitution in 35% and a 10-year survival rate of 30%. Restriction of physical activity is a validated form of therapy with normalization of the heart size in 40 to 60%. Symptomatic medical therapy consists of digitalis, diuretics, ACE-inhibitors and vasodilators and betablocker therapy, where a reduction of mortality was demonstrated in clinical (sub)studies up to 60%. Specific forms of therapy in inflammatory cardiomyopathy rely on the demonstration or lack of viral persistence or signs of autoreactivity in the myocardial tissue. Immunosuppressive therapy in autoimmune forms improved cardiac function in up to 60% of the patients in controlled trials, when compared to controls (40%). The double-blind randomized myocarditis treatment trial, which unfortunately did not distinguish viral from autoimmune myocarditis could not demonstrate such a benefit, however. Depending on the etiology of the disease, immunomodulation with immunoglobulins or interferon or antiviral therapy with hyperimmunoglobulins are presently tested in clinical treatment trials (ESETCID) in patients with enterovirus-positive or cytomegalovirus-positive and adenovirus-positive chronic myocarditis. Specific therapies are aimed to avoid the progression of the disease which may ultimately lead to heart failure with a cardiac assist device or heart transplantation as ultimate therapeutic option.
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Affiliation(s)
- G Hufnagel
- Abteilung Innere Medizin-Schwerpunkt Kardiologie, Philipps-Universität Marburg.
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Abstract
Background
Endomyocardial biopsy is currently the standard method used to diagnose myocarditis. However, it is invasive and has a low diagnostic yield. Because the histological diagnosis of myocarditis requires the presence of myocyte injury, we sought to determine whether measurement of cardiac troponin I (cTnI), which is a serum marker with high sensitivity and specificity for cardiac myocyte injury, could aid in the diagnosis of myocarditis.
Methods and Results
To validate this approach, cTnI values were first measured in mice with autoimmune myocarditis. cTnI values were elevated in 24 of 26 mice with myocarditis but were not elevated in any of the control animals (
P
<.001). Next, cTnI values were measured in the sera from 88 patients referred to the Myocarditis Treatment Trial and were compared with creatine kinase–MB (CK-MB) values measured in the same patients. cTnI values were elevated in 18 (34%) of 53 patients with myocarditis and in only 4 (11%) of 35 patients without myocarditis (
P
=.01). In contrast, CK-MB values were elevated in only 3 (5.7%) of 53 patients with myocarditis and 0 of 35 patients without myocarditis (
P
=.27). Thus, elevations of cTnI occurred more frequently than did elevations of CK-MB in patients with biopsy-proven myocarditis (
P
=.001). Importantly, elevations of cTnI in patients with myocarditis were significantly correlated with ≤1 month duration of heart failure symptoms (
P
=.02), suggesting that the majority of myocyte necrosis occurs early, and thus the window for diagnosis and treatment may be relatively brief.
Conclusions
cTnI was superior to CK-MB for detection of myocyte injury in myocarditis, and cTnI elevations were substantially more common in the first month after the onset of heart failure symptoms.
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Affiliation(s)
- Stacy C. Smith
- the Washington University School of Medicine, Department of Medicine, Cardiovascular Division, St Louis, Mo
| | - Jack H. Ladenson
- the Washington University School of Medicine, Department of Medicine, Cardiovascular Division, St Louis, Mo
| | - Jay W. Mason
- the Washington University School of Medicine, Department of Medicine, Cardiovascular Division, St Louis, Mo
| | - Allan S. Jaffe
- the Washington University School of Medicine, Department of Medicine, Cardiovascular Division, St Louis, Mo
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Mason JW. Immunopathogenesis and treatment of myocarditis: the United States Myocarditis Treatment Trial. J Card Fail 1996; 2:S173-7. [PMID: 8951576 DOI: 10.1016/s1071-9164(96)80074-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J W Mason
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City 84132, USA
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