Cytomegalovirus myocarditis in solid organ transplant recipients: A case series and review of literature

Myocardial Function in Fetuses with Congenital Cytomegalovirus Infection

INTRODUCTION

The objective of this study was to investigate myocardial deformation of left (LV) and right ventricle (RV) using 2-dimensional speckle-tracking echocardiography (2D-STE) in fetuses with and without congenital cytomegalovirus (CMV) infection.

METHODS

This was a prospective single-center study. Vertical transmission was defined by a positive CMV polymerase chain reaction (PCR) test on the amniotic fluid or on the neonate's urine. Fetuses were divided into group 1 and group 2 if CMV-PCR was positive or negative, respectively. LV and RV global longitudinal strain (GLS) values were obtained and adjusted for gestational age by calculating Z-scores. Univariate analysis was carried out to compare cardiac indices between group 1 and group 2.

RESULTS

Fetuses from group 1 (n = 11) had a significantly lower LV myocardial shortening than those from group 2 (n = 32). GLS was -20.7 ± 5.2% and -26.3 ± 4.1%, respectively (p = 0.001). Similarly, GLS Z-score was lower (0.02 ± 0.72) in group 1 than in group 2 (-0.80 ± 0.59) (p = 0.001). Similarly, RV GLS Z-score was significantly impaired in group 1 compared to group 2 (-0.44 ± 1.03 vs. -1.04 ± 0.71, p = 0.041).

CONCLUSION

Fetuses with congenital CMV showed subclinical biventricular myocardial dysfunction. Further studies are needed to confirm the potential role of 2D-STE in identifying fetuses with congenital CMV at risk of postnatal cardiovascular morbidities.

Features of Myocarditis: Morphological Differential Diagnosis in Post-COVID-19 Children

Myocarditis is characterized by dysfunction and destruction of cardiomyocytes, infiltrative inflammation, and development of fibrosis. Late diagnosis of myocarditis has been a serious global health problem, especially due to the spread of a new coronavirus infection. The aim of this review is to identify differences between myocarditis of viral etiology, including SARS-CoV-2 lesions, based on instrumental and pathomorphological findings.

MATERIAL AND METHODS

We analyzed publications covering the period from December 2019 to May 2023, published in publicly accessible international databases ("Medline", "PubMed", "Scopus"), with queries for the keywords "myocarditis", "children", "cardiovascular inflammation", "COVID-19", "SARS-CoV-2", "severe acute respiratory syndrome coronavirus 2", "differential diagnosis".

RESULTS

It was found that no unambiguous morphological criteria for the diagnosis of myocarditis coupled to SARS-CoV-2 lesions were identified. However, the detected histopathological changes such as virus-associated degeneration, apoptosis, cardiomyocyte necrosis, moderate interstitial hyperemia, myocardial tissue oedema, and capillary endothelial cell dysfunction were the major markers of SARS-CoV-2 infection.

CONCLUSION

It is necessary further reconsider morphological criteria to diagnose SARS-CoV-2-caused myocarditis, rather than solely relying on detecting viral RNA by PCR as the sole evidence-based criterion. Similar issues accompany diagnostics of myocardial lesions associated with other viral infections. Evidence for an etiological diagnosis of myocarditis can be provided by a comprehensive analysis of the diagnostic criteria obtained, confirming virus exposure, followed by development of distinct clinical symptoms, MRI and CT changes, and morphological criteria.

Cytomegalovirus infection after renal transplantation

Renal transplant patients show a high prevalence of cytomegalovirus (CMV) infection after the procedure. This study was conducted to assess the prevalence and factors associated with the incidence of CMV infection among renal transplant patients. A total of 100 patients were recruited in this study. The CMV load in the blood of each patient was assessed using the technique of polymerase chain reaction (PCR). The serostatus of all recipients and donors was examined preoperatively and those of the recipients again postoperatively. The association of CMV load was assessed with the following factors: age, gender, alanine aminotransferase (ALT) and serum creatinine levels, types of immunosuppressive and induction regimens, preoperative diabetes status, and serological virologic response (SVR) at 12 weeks postoperatively. Our findings showed that CMV incidence was significantly higher in middle-aged patients (62 of 66 patients, 93.9%; p=0.0001). Furthermore, about 88.2% of patients induced by anti-thymocyte globulin (ATG) showed a high viral load, significantly higher than the proportion of CMV-positive patients induced by basiliximab (p=0.001). In addition, a higher proportion of CMV-negative recipients who received the graft from CMV-positive donors and vice-versa were CMV-positive postoperatively. Administration of Valcyte 450 showed 100% efficiency in decreasing the CMV load in the patients. Among all the assessed factors, only the age of the recipients, type of induction therapy used, and the preoperative serostatus of both donors and recipients were significantly associated with the postoperative CMV incidence among the patients.

Viral Myocarditis-From Pathophysiology to Treatment

The diagnosis of acute and chronic myocarditis remains a challenge for clinicians. Characterization of this disease has been hampered by its diverse etiologies and heterogeneous clinical presentations. Most cases of myocarditis are caused by infectious agents. Despite successful research in the last few years, the pathophysiology of viral myocarditis and its sequelae leading to severe heart failure with a poor prognosis is not fully understood and represents a significant public health issue globally. Most likely, at a certain point, besides viral persistence, several etiological types merge into a common pathogenic autoimmune process leading to chronic inflammation and tissue remodeling, ultimately resulting in the clinical phenotype of dilated cardiomyopathy. Understanding the underlying molecular mechanisms is necessary to assess the prognosis of patients and is fundamental to appropriate specific and personalized therapeutic strategies. To reach this clinical prerequisite, there is the need for advanced diagnostic tools, including an endomyocardial biopsy and guidelines to optimize the management of this disease. The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has currently led to the worst pandemic in a century and has awakened a special sensitivity throughout the world to viral infections. This work aims to summarize the pathophysiology of viral myocarditis, advanced diagnostic methods and the current state of treatment options.