1
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Amelotti N, Brusamolino M, Mapelli M, Contini M, Baggiano A, Fazzari F, Pontone G, Agostoni P. Case report: acute myocarditis in two patients with coronary artery disease presenting with chest pain-thinking outside the box. Eur Heart J Case Rep 2024; 8:ytae220. [PMID: 38736997 PMCID: PMC11087877 DOI: 10.1093/ehjcr/ytae220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 05/14/2024]
Abstract
Background In a subset of patients, acute myocarditis (AM) may mimic acute myocardial infarction, with a similar clinical presentation characterized by chest pain, electrocardiogram (ECG) changes consistent with acute coronary syndromes (ACS), and serum markers increment. Case summary We present two cases of infarct-like myocarditis in patients with known coronary artery disease (CAD), in which the discrepancy between transthoracic echocardiogram findings, ECG, and angiography prompted us to look beyond the simplest diagnosis. In these cases, making a prompt and correct diagnosis is pivotal to address adequate therapy and establish a correct prognosis. Discussion The right diagnosis can avoid unnecessary coronary revascularizations and subsequent antiplatelet therapy that may be associated with an increased haemorrhagic risk. Moreover, it allows setting up guideline-directed therapy for myocarditis, proper follow-up, as well as recommending abstention from physical activity.
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Affiliation(s)
- Nicola Amelotti
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Matteo Brusamolino
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
| | - Andrea Baggiano
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Fabio Fazzari
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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2
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Costa C, Moniati F. The Epidemiology of COVID-19 Vaccine-Induced Myocarditis. Adv Med 2024; 2024:4470326. [PMID: 38681683 PMCID: PMC11045291 DOI: 10.1155/2024/4470326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/26/2024] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Background In December 2019, the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) led to the COVID-19 pandemic, with millions of deaths worldwide. Vaccine breakthroughs in late 2020 resulted in the authorization of COVID-19 vaccines. While these vaccines have demonstrated efficacy, evidence from vaccine safety monitoring systems around the globe supported a causal association between COVID-19 vaccines, in particular those using mRNA technology, i.e., Moderna's mRNA-1273 and Pfizer-BioNTech's BNT162b2, and myocarditis. Objective This paper aims to investigate the epidemiology of mRNA COVID-19 vaccine-induced myocarditis, including age, ethnicity, and gender associations with these vaccines. It also discusses the immunopathophysiological mechanisms of mRNA COVID-19 vaccine-associated myocarditis and outlines principles of diagnosis, clinical presentation, and management. Methods A literature review was conducted using PubMed, Embase, and Queen Mary University of London Library Services databases. Search terms included "myocarditis," "coronavirus disease 2019," "SARS-CoV-2," "mRNA Covid-19 vaccines," "Covid vaccine-associated myocarditis," "epidemiology," "potential mechanisms," "myocarditis diagnosis," and "myocarditis management." Results While the definite mechanism of mRNA COVID-19 vaccine-associated myocarditis remains ambiguous, potential mechanisms include molecular mimicry of spike proteins and activation of the adaptive immune response with dysregulated cytokine expression. Male predominance in COVID-19 vaccine-induced myocarditis may be attributed to sex hormones, variations in inflammatory reactions, coagulation states based on gender, and female-specific protective factors. Moreover, an analysis of diagnostic and management strategies reveals a lack of consensus on acute patient presentation management. Conclusion In contrast to viral infections that stand as the predominant etiological factor for myocarditis with more severe consequences, the mRNA COVID-19 vaccination elicits a mild and self-limiting manifestation of the condition. There is currently insufficient evidence to confirm the definite underlying mechanism of COVID-19 vaccine-associated myocarditis. Further research is needed to develop preventive and therapeutic solutions in this context.
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Affiliation(s)
| | - Foteini Moniati
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, London, UK
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3
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Baglini E, Poggetti V, Cavallini C, Petroni D, Forini F, Nicolini G, Barresi E, Salerno S, Costa B, Iozzo P, Neglia D, Menichetti L, Taliani S, Da Settimo F. Targeting the Translocator Protein (18 kDa) in Cardiac Diseases: State of the Art and Future Opportunities. J Med Chem 2024; 67:17-37. [PMID: 38113353 PMCID: PMC10911791 DOI: 10.1021/acs.jmedchem.3c01716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/21/2023]
Abstract
Mitochondria dysfunctions are typical hallmarks of cardiac disorders (CDs). The multiple tasks of this energy-producing organelle are well documented, but its pathophysiologic involvement in several manifestations of heart diseases, such as altered electromechanical coupling, excitability, and arrhythmias, is still under investigation. The human 18 kDa translocator protein (TSPO) is a protein located on the outer mitochondrial membrane whose expression is altered in different pathological conditions, including CDs, making it an attractive therapeutic and diagnostic target. Currently, only a few TSPO ligands are employed in CDs and cardiac imaging. In this Perspective, we report an overview of the emerging role of TSPO at the heart level, focusing on the recent literature concerning the development of TSPO ligands used for fighting and imaging heart-related disease conditions. Accordingly, targeting TSPO might represent a successful strategy to achieve novel therapeutic and diagnostic strategies to unravel the fundamental mechanisms and to provide solutions to still unanswered questions in CDs.
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Affiliation(s)
- Emma Baglini
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Valeria Poggetti
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
| | - Chiara Cavallini
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Debora Petroni
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Francesca Forini
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Giuseppina Nicolini
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Elisabetta Barresi
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
| | - Silvia Salerno
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
| | - Barbara Costa
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
| | - Patricia Iozzo
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Danilo Neglia
- Fondazione
CNR/Regione Toscana Gabriele Monasterio, Cardiovascular and Imaging
Departments, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Luca Menichetti
- Institute
of Clinical Physiology, National Research Council of Italy, CNR Research Area, Via G. Moruzzi 1, Pisa 56124, Italy
| | - Sabrina Taliani
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
| | - Federico Da Settimo
- Department
of Pharmacy, University of Pisa, Via Bonanno 6, Pisa 56126, Italy
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4
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Lasica R, Djukanovic L, Savic L, Krljanac G, Zdravkovic M, Ristic M, Lasica A, Asanin M, Ristic A. Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment. Diagnostics (Basel) 2023; 13:3073. [PMID: 37835816 PMCID: PMC10572782 DOI: 10.3390/diagnostics13193073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Although the frequency of myocarditis in the general population is very difficult to accurately determine due to the large number of asymptomatic cases, the incidence of this disease is increasing significantly due to better defined criteria for diagnosis and the development of modern diagnostic methods. The multitude of different etiological factors, the diversity of the clinical picture, and the variability of the diagnostic findings make this disease often demanding both for the selection of the diagnostic modality and for the proper therapeutic approach. The previously known most common viral etiology of this disease is today overshadowed by new findings based on immune-mediated processes, associated with diseases that in their natural course can lead to myocardial involvement, as well as the iatrogenic cause of myocarditis, which is due to use of immune checkpoint inhibitors in the treatment of cancer patients. Suspecting that a patient with polymorphic and non-specific clinical signs and symptoms, such as changes in ECG and echocardiography readings, has myocarditis is the starting point in the diagnostic algorithm. Cardio magnetic resonance imaging is non-invasive and is the gold standard for diagnosis and clinical follow-up of these patients. Endomyocardial biopsy as an invasive method is the diagnostic choice in life-threatening cases with suspicion of fulminant myocarditis where the diagnosis has not yet established or there is no adequate response to the applied therapeutic regimen. The treatment of myocarditis is increasingly demanding and includes conservative methods of treating heart failure, immunomodulatory and immunospressive therapy, methods of mechanical circulatory support, and heart transplantation. The goal of developing new diagnostic and therapeutic methods is to reduce mortality from this complex disease, which is still high.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Gordana Krljanac
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Marija Zdravkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Medical Center Bezanijska Kosa, 11000 Belgrade, Serbia
| | - Marko Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | | | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Arsen Ristic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
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5
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Alamri AS, Khayat LT, Alzahrani AJ, Kurdi LK, Alkhameesi NF, Bahaidarah SA. Clinical Presentation of Myocarditis in the Pediatric Age Group and Predictors of Poor Early and Late Outcomes: Academic Hospital Experience. Cureus 2022; 14:e31643. [DOI: 10.7759/cureus.31643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 11/19/2022] Open
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6
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Montera MW, Marcondes-Braga FG, Simões MV, Moura LAZ, Fernandes F, Mangine S, Oliveira Júnior ACD, Souza ALADAGD, Ianni BM, Rochitte CE, Mesquita CT, de Azevedo Filho CF, Freitas DCDA, Melo DTPD, Bocchi EA, Horowitz ESK, Mesquita ET, Oliveira GH, Villacorta H, Rossi Neto JM, Barbosa JMB, Figueiredo Neto JAD, Luiz LF, Hajjar LA, Beck-da-Silva L, Campos LADA, Danzmann LC, Bittencourt MI, Garcia MI, Avila MS, Clausell NO, Oliveira NAD, Silvestre OM, Souza OFD, Mourilhe-Rocha R, Kalil Filho R, Al-Kindi SG, Rassi S, Alves SMM, Ferreira SMA, Rizk SI, Mattos TAC, Barzilai V, Martins WDA, Schultheiss HP. Brazilian Society of Cardiology Guideline on Myocarditis - 2022. Arq Bras Cardiol 2022; 119:143-211. [PMID: 35830116 PMCID: PMC9352123 DOI: 10.36660/abc.20220412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Fabiana G Marcondes-Braga
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Marcus Vinícius Simões
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Fabio Fernandes
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Sandrigo Mangine
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Bárbara Maria Ianni
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital do Coração (HCOR), São Paulo, SP - Brasil
| | - Claudio Tinoco Mesquita
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil.,Universidade Federal Fluminense,Rio de Janeiro, RJ - Brasil.,Hospital Vitória, Rio de Janeiro, RJ - Brasil
| | | | | | | | - Edimar Alcides Bocchi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Evandro Tinoco Mesquita
- Universidade Federal Fluminense,Rio de Janeiro, RJ - Brasil.,Centro de Ensino e Treinamento Edson de Godoy Bueno / UHG, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Ludhmila Abrahão Hajjar
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil.,Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luis Beck-da-Silva
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil.,Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Imbroise Bittencourt
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ - Brasil.,Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ - Brasil
| | - Marcelo Iorio Garcia
- Hospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | - Monica Samuel Avila
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - Sadeer G Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University,Cleveland, Ohio - EUA
| | | | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE - Brasil.,Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | - Silvia Moreira Ayub Ferreira
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Stéphanie Itala Rizk
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Sírio Libanês, São Paulo, SP - Brasil
| | | | - Vitor Barzilai
- Instituto de Cardiologia do Distrito Federal, Brasília, DF - Brasil
| | - Wolney de Andrade Martins
- Universidade Federal Fluminense,Rio de Janeiro, RJ - Brasil.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
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7
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Schmutzler L, Mirna M, Hoppe UC, Lichtenauer M. From Streptococcal Pharyngitis/Tonsillitis to Myocarditis: A Systematic Review. J Cardiovasc Dev Dis 2022; 9:jcdd9060170. [PMID: 35735799 PMCID: PMC9224538 DOI: 10.3390/jcdd9060170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 02/05/2023] Open
Abstract
(1) Background: Myocarditis following group A streptococcal pharyngitis and tonsillitis is a relatively rare medical condition. The aim of this systematic review was to identify specific ECG changes, laboratory parameters and signs, and symptoms associated with this disease. (2) Methods: A systematic literature review was performed in concordance with the current PRISMA guidelines, including the databases PubMed/MEDLINE, Web of Science, CDSR, CENTRAL, CCAs, EBM Reviews, and LILACS. Articles were included if they covered myocarditis after streptococcal pharyngitis/tonsillitis in humans. Exclusion criteria were rheumatic, autoimmune, or toxic myocarditis. (3) Results: Patients that developed myocarditis after group A streptococcal throat infection frequently presented with chest pain, elevated cardiac markers, and ST-segment elevations, making it a condition that shows more similarities to acute coronary syndrome than viral myocarditis. (4) Conclusions: Myocarditis after streptococcal pharyngitis and/or tonsillitis is a rather infrequently described disease; however, it is necessary to consider this condition when investigating streptococcal sore throat because it can be associated with severe adverse events for the individual patient.
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Affiliation(s)
| | - Moritz Mirna
- Correspondence: (L.S.); (M.M.); Tel.: +43-(0)57255-58340 (M.M.)
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8
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Pediatric Myocarditis: What Have We Learnt So Far? J Cardiovasc Dev Dis 2022; 9:jcdd9050143. [PMID: 35621854 PMCID: PMC9144089 DOI: 10.3390/jcdd9050143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Myocarditis is an inflammatory disease of the myocardium that is troublesome to diagnose and manage, especially in children. Since the introduction of endomyocardial biopsy (EMB), new diagnostic tools have provided useful data. Especially when enhanced with immunohistochemistry and polymerase chain reaction (PCR) studies, EMB remains the gold standard for the diagnosis. Notably, cardiac magnetic resonance (MRI) is a non-invasive tool that can confirm the diagnosis and has a particular usefulness during the follow-up. The causes of myocarditis are heterogeneous (mostly viral in children). The course and outcome of the illness in the pediatric population represent a complex interaction between etiologic agents and the immune system, which is still not fully understood. The clinical presentation and course of myocarditis vary widely from paucisymptomatic illness to acute heart failure refractory to therapy, arrhythmias, angina-like presentation and sudden cardiac death. In this setting, cardiac biomarkers (i.e., troponins and BNP), although unspecific, can be used to support the diagnosis. Finally, the efficacy of therapeutic strategies is controversial and not confirmed by clinical trials. In this review, we summarized the milestones in diagnosis and provided an overview of the therapeutic options for myocarditis in children.
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9
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Power JR, Keyt LK, Adler ED. Myocarditis following COVID-19 vaccination: incidence, mechanisms, and clinical considerations. Expert Rev Cardiovasc Ther 2022; 20:241-251. [PMID: 35414326 PMCID: PMC9115793 DOI: 10.1080/14779072.2022.2066522] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Vaccines have demonstrated protection against the morbidity and mortality of COVID-19, but concerns regarding the rare side effect of acute myocarditis have stymied immunization efforts. This review aims to describe the incidence and theorized mechanisms of COVID vaccine-associated myocarditis and review relevant principles for management of vaccine-associated myocarditis. AREAS COVERED Epidemiologic studies of myocarditis after COVID vaccination are reviewed, which show an incidence of approximately 20-30 per million patients. The vast majority of these cases are seen with mRNA vaccines especially in male patients under 30 years of age. Mechanisms are largely theoretical, but molecular mimicry and dysregulated innate immune reactions have been proposed. While studies suggest that this subtype of myocarditis is mild and self-limited, long-term evidence is lacking. Principles of myocarditis treatment and surveillance are outlined as they apply to COVID vaccine-associated myocarditis. EXPERT OPINION COVID vaccine-associated myocarditis is rare but well described in certain at-risk groups. Better understanding of its pathogenesis is key to mitigating this complication and advancing vaccination efforts. Risk-benefit analyses demonstrate that individual- and population-level benefits of vaccination exceed the risks of this rare and mild form of myocarditis.
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Affiliation(s)
- John R. Power
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
| | - Lucas K. Keyt
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
| | - Eric D. Adler
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, United States
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10
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Asllanaj B, Chang E, Dota A, McWhorter Y. Viral Myocarditis Mimicking ST-Segment Elevation Myocardial Infarction Complicated by Thrombocytopenia and Vasculitic Peripheral Neuropathy. J Investig Med High Impact Case Rep 2022; 10:23247096221139271. [PMID: 36433700 PMCID: PMC9703478 DOI: 10.1177/23247096221139271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/28/2022] [Accepted: 10/29/2022] [Indexed: 11/02/2023] Open
Abstract
Symptomatic myocarditis is classically featured by a flu-like prodrome, dyspnea on exertion, palpitations, substernal chest pain, and abnormal electrocardiogram (ECG). The clinical diagnosis has often been challenging due to its similarities to acute coronary syndrome. Our case involved a patient who presented with claudication of bilateral lower extremity and ST-segment elevation myocardial infarction (STEMI) in the inferior leads. On cardiac catheterization, nonobstructed coronary arteries with left ventricular ejection fraction (LVEF) of 30% were demonstrated. His clinical presentation was consistent with suspected myocarditis, and he improved with immunosuppression. In addition, his thrombocytopenia and severe symptoms of peripheral neuropathy responded to both immunotherapy and anticoagulation. This case highlights the interplay between history taking, physical examination, and multimodal diagnostic imaging.
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Affiliation(s)
| | - Eric Chang
- MountainView Hospital, Las Vegas, NV, USA
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11
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Tuan TA, Xoay TD, Phuc PH, Hung DV, Dung NT, Truong NLT, Thuan NV, Dien TM. Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam. Front Cardiovasc Med 2021; 8:741260. [PMID: 34912858 PMCID: PMC8666974 DOI: 10.3389/fcvm.2021.741260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
Objective: Data on the management and outcomes of acute myocarditis treated with extracorporeal membrane oxygenation (ECMO) among low- and middle-income countries are limited. This study aimed to determine the short-term outcomes and also identify factors associated with ECMO use among children with acute myocarditis at a tertiary children's hospital in Vietnam. Methods: A single-center, retrospective observational study was conducted between January 2016 and February 2021. Pediatric patients with acute myocarditis, aged 1 month to 16 years, were included. Results: In total, 54 patients (male, 46%; median age, 7 years) with acute myocarditis were included; 37 of them received ECMO support. Thirty percent (16/54) of the patients died, and 12 of them received ECMO. Laboratory variables that differed between survivors and non-survivors included median left ventricular ejection fraction (LVEF) at 48 h (42 vs. 25%; p = 0.001), platelet count (304 g/L [interquartile range (IQR): 243-271] vs. 219 g/L [IQR: 167-297]; p = 0.014), and protein (60 g/dl [IQR: 54-69] vs. 55 [IQR: 50-58]; p = 0.025). Among patients who received ECMO, compared with the survivors, non-survivors had a low LVEF at 48 h (odds ratio (OR), 0.8; 95% confidence interval (CI): 0.6-0.9; p = 0.006) and high vasoactive-inotropic score (OR, 1.0; 95% CI: 1.0-1.0; p = 0.038) and lactate (OR, 2.8; 95% CI, 1.2-6.1; p = 0.013) at 24 h post-ECMO. Conclusions: The case fatality rate among children with acute myocarditis was 30 and 32% among patients requiring ECMO support. Arrhythmia was an indicator for ECMO in patients with cardiogenic shock.
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Affiliation(s)
- Ta Anh Tuan
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam.,Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.,Department of Pediatric, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Dang Xoay
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Phan Huu Phuc
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Dau Viet Hung
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam.,Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Nguyen Trong Dung
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Nguyen Ly Thinh Truong
- Department of Cardiovascular Surgery, Children Heart Center, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Nguyen Van Thuan
- Surgical Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Tran Minh Dien
- Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.,Surgical Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
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Escher F, Aleshcheva G, Pietsch H, Baumeier C, Gross UM, Schrage BN, Westermann D, Bock CT, Schultheiss HP. Transcriptional Active Parvovirus B19 Infection Predicts Adverse Long-Term Outcome in Patients with Non-Ischemic Cardiomyopathy. Biomedicines 2021; 9:biomedicines9121898. [PMID: 34944716 PMCID: PMC8698988 DOI: 10.3390/biomedicines9121898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022] Open
Abstract
Parvovirus B19 (B19V) is the predominant cardiotropic virus currently found in endomyocardial biopsies (EMBs). However, direct evidence showing a causal relationship between B19V and progression of inflammatory cardiomyopathy are still missing. The aim of this study was to analyze the impact of transcriptionally active cardiotropic B19V infection determined by viral RNA expression upon long-term outcomes in a large cohort of adult patients with non-ischemic cardiomyopathy in a retrospective analysis from a prospective observational cohort. In total, the analyzed study group comprised 871 consecutive B19V-positive patients (mean age 50.0 ± 15.0 years) with non-ischemic cardiomyopathy who underwent EMB. B19V-positivity was ascertained by routine diagnosis of viral genomes in EMBs. Molecular analysis of EMB revealed positive B19V transcriptional activity in n = 165 patients (18.9%). Primary endpoint was all-cause mortality in the overall cohort. The patients were followed up to 60 months. On the Cox regression analysis, B19V transcriptional activity was predictive of a worse prognosis compared to those without actively replicating B19V (p = 0.01). Moreover, multivariable analysis revealed transcriptional active B19V combined with inflammation [hazard ratio 4.013, 95% confidence interval 1.515–10.629 (p = 0.005)] as the strongest predictor of impaired survival even after adjustment for age and baseline LVEF (p = 0.005) and independently of viral load. The study demonstrates for the first time the pathogenic clinical importance of B19V with transcriptional activity in a large cohort of patients. Transcriptionally active B19V infection is an unfavourable prognostic trigger of adverse outcome. Our findings are of high clinical relevance, indicating that advanced diagnostic differentiation of B19V positive patients is of high prognostic importance.
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Affiliation(s)
- Felicitas Escher
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin and Humboldt-Universitaet zu Berlin, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Correspondence:
| | - Ganna Aleshcheva
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
| | - Heiko Pietsch
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin and Humboldt-Universitaet zu Berlin, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
| | - Christian Baumeier
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
| | - Ulrich M. Gross
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
| | - Benedikt Norbert Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (B.N.S.); (D.W.)
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (B.N.S.); (D.W.)
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany
| | - Claus-Thomas Bock
- Department of Infectious Diseases, Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Robert Koch Institute, 13353 Berlin, Germany;
- Institute of Tropical Medicine, University of Tuebingen, 72074 Tuebingen, Germany
| | - Heinz-Peter Schultheiss
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (G.A.); (H.P.); (C.B.); (U.M.G.); (H.-P.S.)
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13
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Assessment of Coronary Inflammation by Pericoronary Fat Attenuation Index in Clinically Suspected Myocarditis with Infarct-Like Presentation. J Clin Med 2021; 10:jcm10184200. [PMID: 34575310 PMCID: PMC8465666 DOI: 10.3390/jcm10184200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
Background: The pathophysiology of angina-like symptoms in myocarditis is still unclear. Perivascular fat attenuation index (pFAI) by coronary computed tomography angiography (CCTA) is a non-invasive marker of coronary inflammation (CI) in atherosclerosis. We explored the presence of CI in clinically suspected myocarditis with infarct-like presentation. Methods: We retrospectively included 15 consecutive patients (67% male, age 30 ± 10 years) with clinically suspected infarct-like myocarditis who underwent CCTA to rule out coronary artery disease. Right coronary artery (RCA) pFAI mean value was compared with that of healthy volunteers. Results: Mean RCA pFAI value was −92.8 ± 8.4 HU, similar to that of healthy volunteers (−95.2 ± 6.0, p = 0.8). We found no correlation between RCA pFAI mean values and peak Troponin I (r = −0.43, p = 0.11) and C-reactive protein at diagnosis (r = −0.25, p = 0.42). Patients with higher pFAI values showed higher biventricular end-systolic volumes (ESV) (p = 0.038 for left and p = 0.024 for right ventricle) and lower right ventricular ejection fraction (RVEF) (p = 0.038) on cardiovascular magnetic resonance. Conclusions: In clinically suspected myocarditis with infarct-like presentation, RCA pFAI values are lower than those validated in atherosclerosis. The correlation between higher pFAI values, higher biventricular ESV and lower RVEF, may suggest a role of pFAI in predicting non-atherosclerotic CI (i.e., infective/immune-mediated “endothelialitis”).
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14
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Fung RCM, Hon KL, Leung AKC. Acute Myocarditis in Children: An Overview of Treatment and Recent Patents. ACTA ACUST UNITED AC 2021; 14:106-116. [PMID: 32013855 DOI: 10.2174/1872213x14666200204103714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis. METHODS Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine. RESULTS Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking. CONCLUSION This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.
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Affiliation(s)
- Ronald C M Fung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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15
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Fernando A, Guragai N, Vasudev R, Pullatt R, Randhawa P. A Rare Case of Myocarditis Mimicking ST-Elevation Myocardial Infarction. Cureus 2020; 12:e11671. [PMID: 33391909 PMCID: PMC7769724 DOI: 10.7759/cureus.11671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myocarditis is caused by acute injury and inflammation of cardiac myocytes and is most commonly caused by a viral infection. Myocarditis remains a rare diagnosis and manifests with a wide spectrum of non-specific symptoms that include chest pain, dyspnea, and palpitations associated with electrocardiographic abnormalities that resemble that of ST-elevation myocardial infarction (STEMI). Therefore, clinical diagnosis is often challenging and is often misdiagnosed. We present a case of a 22-year-old male who presented with left-sided non-radiating chest pain associated with shortness of breath, elevated troponin of 3.2 ng/ml (<0.03 ng/ml). Electrocardiogram (ECG) and cardiac echocardiogram revealed ST-segment elevations in the anterolateral leads and an ejection fraction of 35%, respectively. The patient was initially suspected of having a STEMI; however, cardiac catheterization revealed non-obstructed coronary arteries. Due to elevated inflammatory markers, the patient was then started on colchicine for suspected myocarditis and had complete resolution of symptoms one week after. This case highlights that a high index of clinical suspicion and prompt diagnosis is necessary to prevent any delays in appropriate therapy for myocarditis.
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Affiliation(s)
- Ashen Fernando
- Cardiology, St. George's University School of Medicine, True Blue, GRD
| | - Nirmal Guragai
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Rahul Vasudev
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Raja Pullatt
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
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16
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Uziębło-Życzkowska B, Mielniczuk M, Ryczek R, Krzesiński P. Myocarditis successfully diagnosed and controlled with speckle tracking echocardiography. Cardiovasc Ultrasound 2020; 18:19. [PMID: 32532287 PMCID: PMC7293120 DOI: 10.1186/s12947-020-00203-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background Speckle tracking echocardiography (STE) is an objective, well-validated and reproducible technique of assessing left ventricular longitudinal deformation; it also offers a more sensitive assessment of myocardial contractility than widely used visual estimation. Evaluating global longitudinal strain may help identify patients with subclinical left ventricular systolic dysfunction. Case presentation We report the case of a 28-year-old man with myocarditis, which successfully diagnosed and followed-up with the novel echocardiography method using speckle tracking imaging. The patient was referred to our hospital with an initial diagnosis of ST-segment elevation myocardial infarction. Transthoracic echocardiography did not show any contractility abnormalities. Hence, in the course of further diagnostics, left ventricular function was assessed by STE. Depressed global longitudinal strain was noted within several segments of the left ventricle. Then, cardiac magnetic resonance imaging was performed to confirm the diagnosis of myocarditis. Conclusions STE seems to be competitive in relation to cardiac magnetic resonance imaging in the diagnosis of some diseases, such as myocarditis.
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Affiliation(s)
- Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland.
| | - Marta Mielniczuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
| | - Robert Ryczek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
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17
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Ying W, Pinilla-Vera M, Zakaria S. Acute myopericarditis as a cause of isolated right ventricular failure. Future Cardiol 2020; 16:171-178. [DOI: 10.2217/fca-2019-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Myopericarditis is characterized by pericardial and myocardial inflammation and is a known cause of chest pain and heart failure. It is primarily associated with biventricular or left ventricular dysfunction. We describe an unusual case of a 57-year-old woman with myopericarditis causing isolated right ventricular (RV) failure. She initially presented with chest pain and cardiogenic shock and was found to have acute RV dysfunction with a normally functioning left ventricle. After excluding more common causes of RV failure, she was diagnosed with acute myopericarditis. In this report, we discuss the differential diagnoses and work-up of acute RV failure, as well as review prior cases of RV-predominant myocarditis/myopericarditis. We highlight the importance of recognizing isolated RV failure as a possible, but rare, presentation of myopericarditis.
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Affiliation(s)
- Wendy Ying
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Miguel Pinilla-Vera
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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18
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Olejniczak M, Schwartz M, Webber E, Shaffer A, Perry TE. Viral Myocarditis-Incidence, Diagnosis and Management. J Cardiothorac Vasc Anesth 2020; 34:1591-1601. [PMID: 32127272 DOI: 10.1053/j.jvca.2019.12.052] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 12/25/2022]
Abstract
Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.
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Affiliation(s)
- Megan Olejniczak
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Matthew Schwartz
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Elizabeth Webber
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Andrew Shaffer
- University of Minnesota, Department of Cardiothoracic Surgery, Minneapolis, MN
| | - Tjorvi E Perry
- University of Minnesota, Department of Anesthesia, Minneapolis, MN.
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19
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Wu H, Su Z, Barnie PA. The role of B regulatory (B10) cells in inflammatory disorders and their potential as therapeutic targets. Int Immunopharmacol 2019; 78:106111. [PMID: 31881524 DOI: 10.1016/j.intimp.2019.106111] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/08/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Over the past decade, studies have identified subset of B cells, which play suppressive functions in additions to the conventional functions of B cells: antigen processing and presentation, activation of T cells and antibody productions. Because of their regulatory function, they were named as B regulatory cells (Bregs). Bregs restrict the severity of autoimmune disorders in animal disease models such as experimental autoimmune myocarditis (EAM), experimental autoimmune encephalitis (EAE), and collagen-induced arthritis (CIA) but can contribute to the development of infection and cancer. In humans, the roles of B regulatory cells in autoimmune diseases have not been clearly established because of the inconsistent findings from many researchers. This is believed to arise from the speculated fact that Bregs lack specific marker, which can be used to identify and characterize them in human diseases. The CD19+CD24hiCD38hiCD1dhiB cells have been associated with the regulatory function. Available evidences highlight the relevance of increasing IL-10-producing B cells in autoimmune diseases and the possibility of serving as new therapeutic targets in inflammatory disorders. This review empanels the functions of Bregs in autoimmune diseases in both human and animal models, and further evaluates the possibility of Bregs as therapeutic targets in inflammatory disorders. Consequently, this might help identify possible research gaps, which need to be clarified as researchers speculate the possibility of targeting some subsets of Bregs in the treatment of inflammatory disorders.
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Affiliation(s)
- Hongxia Wu
- Department of Laboratory, People's Hospital of Jiangyin, Jiangsu 214400, China
| | - Zhaoliang Su
- International Genome Center, Jiangsu University, Zhenjiang 212013, China
| | - Prince Amoah Barnie
- International Genome Center, Jiangsu University, Zhenjiang 212013, China; Department of Biomedical Sciences, School of Allied Health Sciences, University of Cape Coast, Ghana.
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20
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Buttà C, Zappia L, Laterra G, Roberto M. Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Ann Noninvasive Electrocardiol 2019; 25. [PMID: 31778001 PMCID: PMC7958927 DOI: 10.1111/anec.12726] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/28/2019] [Accepted: 10/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non‐specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis. Methods We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield. Results The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T‐wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high‐degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis. Conclusions ECG alterations in acute myocarditis could be very useful in clinical practice for a patient‐tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.
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Affiliation(s)
- Carmelo Buttà
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Zappia
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giulia Laterra
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marco Roberto
- Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
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21
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Dasgupta S, Iannucci G, Mao C, Clabby M, Oster ME. Myocarditis in the pediatric population: A review. CONGENIT HEART DIS 2019; 14:868-877. [DOI: 10.1111/chd.12835] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Glen Iannucci
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Chad Mao
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Martha Clabby
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
| | - Matthew E. Oster
- Division of Pediatric Cardiology, Department of Pediatrics Children's Healthcare of Atlanta, Emory University Atlanta Georgia
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22
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Katzmann JL, Schlattmann P, Rigopoulos AG, Noutsias E, Bigalke B, Pauschinger M, Tschope C, Sedding D, Schulze PC, Noutsias M. Meta-analysis on the immunohistological detection of inflammatory cardiomyopathy in endomyocardial biopsies. Heart Fail Rev 2019; 25:277-294. [DOI: 10.1007/s10741-019-09835-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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23
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Mirna M, Paar V, Kraus T, Sotlar K, Wernly B, Pistulli R, Hoppe UC, Lichtenauer M. Autoimmune myocarditis is not associated with left ventricular systolic dysfunction. Eur J Clin Invest 2019; 49:e13132. [PMID: 31125424 PMCID: PMC6771695 DOI: 10.1111/eci.13132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Experimental autoimmune myocarditis (EAM) is a common animal model for the investigation of the pathophysiology of myocarditis. Because of diverging findings from previous studies, we performed serial echocardiographic examinations throughout the course of the disease and investigated the dimensions of the murine heart and left ventricular (LV) systolic function. MATERIALS AND METHODS Experimental autoimmune myocarditis was induced in male Balb/c mice by subcutaneous injection of a fragment of the α-myosin heavy chain (MyHC-α 614-629: Ac-SLKLMATLFSTYASAD). Transthoracic echocardiography was performed on days 0, 7 and 21 in healthy animals and mice with EAM. RESULTS Experimental autoimmune myocarditis was associated with a reduction in LV systolic function and an increase in LV internal diameter in diastole (LVIDd) and systole (LVIDs) 7 days postimmunization. After 21 days, EAM led to a significant increase in LV-thickness (1.3-fold increase in LV anterior wall diameter in diastole [LVAWDd]), but there was no difference in LV systolic function between immunized animals and healthy controls. LV-thickness correlated well with the severity of myocarditis in the histopathological examination (LVAWDd: rs = 0.603, P = 0.003, LV anterior wall diameter in systole (LVAWDs): rs = 0.718, P < 0.0001). CONCLUSION Our results indicate that EAM leads to an initial dilatation of the LV that is followed by ventricular "hypertrophy." On day 21, there was no significant difference in LV systolic function between immunized animals and controls. Furthermore, the ageing of the animals had a major impact on the echocardiographic parameters; therefore, the use of healthy age-matched controls seems warranted when echocardiography is performed in rodents.
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Affiliation(s)
- Moritz Mirna
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Vera Paar
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Theo Kraus
- Institute of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Rudin Pistulli
- Department of Cardiology I, Coronary and Peripheral Vascular Diseases, Heart Failure, University Hospital Münster, Münster, Germany
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
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24
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The spectrum of myocarditis: from pathology to the clinics. Virchows Arch 2019; 475:279-301. [DOI: 10.1007/s00428-019-02615-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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25
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Lam L, Sathirareuangchai S, Oyama J, Devendra G, Hong R. Lymphocytic Myocarditis and Cardiogenic Shock in Hawai'i: A Case Series. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2019; 78:223-229. [PMID: 31475250 PMCID: PMC6697651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Lymphocytic myocarditis is an inflammatory disease of the heart that may present in a myriad of fashions ranging from mild febrile illness to florid myocarditis and cardiogenic shock. Given its nonspecific clinical presentation, the diagnosis of lymphocytic myocarditis is often challenging. The authors describe four cases of lymphocytic myocarditis in young women who presented with cardiogenic shock. Two patients survived and two died. This presentation has not been seen previously in Hawai'i and the public awareness of this condition is critical. Early diagnosis and the prompt initiation of biventricular mechanical circulatory support appear to have been critical in improving patient survival.
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Affiliation(s)
- Luke Lam
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (LL, SS, JO, GD)
- The Queen's Medical Center, Honolulu, HI (RH)
| | - Sakda Sathirareuangchai
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (LL, SS, JO, GD)
- The Queen's Medical Center, Honolulu, HI (RH)
| | - Jared Oyama
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (LL, SS, JO, GD)
- The Queen's Medical Center, Honolulu, HI (RH)
| | - Gehan Devendra
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (LL, SS, JO, GD)
- The Queen's Medical Center, Honolulu, HI (RH)
| | - Robert Hong
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (LL, SS, JO, GD)
- The Queen's Medical Center, Honolulu, HI (RH)
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Systematic Review of PCR Proof of Parvovirus B19 Genomes in Endomyocardial Biopsies of Patients Presenting with Myocarditis or Dilated Cardiomyopathy. Viruses 2019; 11:v11060566. [PMID: 31216741 PMCID: PMC6631559 DOI: 10.3390/v11060566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Diverse viral infections have been associated with myocarditis (MC) and dilated cardiomyopathy (DCM). In this meta-analysis, we summarize the published results on the association of parvovirus B19 (B19V) genomes with human MC/DCM versus controls. Methods: n = 197 publications referring to B19V and MC or DCM were retrieved using multiple PubMed search modes. Out of these, n = 29 publications met the inclusion criteria with data from prospective analyses on >10 unselected patients presenting with MC or DCM (dataset: MA01). Data retrieved simultaneously from both controls and MC/DCM patients were available from n = 8 from these publications (dataset: MA02). Results: In the dataset MA01 B19V genomes were detected in 42.6% of the endomyocardial biopsies (EMB) in this cohort by PCR. In the dataset MA02 comprising n = 638 subjects, there was no statistically significant different rate of B19V positivity in myocardial tissues comparing controls (mean: 38.8 + 24.1%) versus the MC/DCM-patients (45.5 + 24.3%; p = 0.58). There was also no statistical difference between the positivity rate of B19V genomes in myocardial tissues of MA01 (46.0 + 19.5%) and the two patient groups of MA02 (p > 0.05). Conclusions: This systematic review reveals that the mean rate of PCR detected B19V genomes in patients presenting with MC/DCM does not differ significantly from the findings in control myocardial tissues. These data imply pathogenetically insignificant latency of B19V genomes in a proportion of myocardial tissues, both in MC-/DCM-patients and in controls. More information (i.e., replicative status, viral protein expression) is pertinent to achieve a comprehensive workup of myocardial B19V infection.
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Jacobson A, Sutthiwan P. Myocarditis: A rare manifestation of acute Q fever infection. J Cardiol Cases 2019; 20:45-48. [PMID: 31440310 DOI: 10.1016/j.jccase.2019.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/03/2019] [Accepted: 03/22/2019] [Indexed: 12/20/2022] Open
Abstract
Myocarditis is a rare disease manifestation of acute Q fever caused by infection with Coxiella burnetii, an infectious Gram-negative proteobacteria. C. burnetii has a large animal reservoir and is often transmitted to humans during animal birth. Acute Q fever has a nonspecific disease presentation leading to delayed treatment and potentially worsened clinical outcomes. We describe a case of an otherwise healthy adult man with angina, ST elevations, and positive cardiac troponins-all findings suggestive of acute coronary syndrome. Cardiac catheterization revealed no significant coronary blockages or abnormalities. On echocardiography he was found to have heart failure with reduced ejection fraction. The patient's social history included several risk factors for Q fever. Serologic testing returned positive for anti-C. burnetii antibodies, and a diagnosis of acute Q fever myocarditis was made. The patient was appropriately treated with a course of doxycycline and clinically improved. <Learning objective: Q fever has a nonspecific presentation often leading to a delayed or missed diagnosis, resulting in worsened morbidity and mortality. Patients with angina-like chest pain and risk factors for Q fever should promptly be tested for infection with C. burnetii. Cardiac magnetic resonance imaging is a useful tool to improve diagnostic accuracy, with positive serology confirming the diagnosis. Treatment includes a course of antibiotics-often doxycycline.>.
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Stukalova OV, Gupalo EM, Chumachenko PV, Samko AN, Butorova EA, Shakhnovich RM, Mironova NA, Narusov OY, Safiullina AA, Shariya MA, Golitsyn SP, Ternovoy SK, Chazova IE. The value of cardiovascular magnetic resonance in myocarditis with different clinical presentation. TERAPEVT ARKH 2019; 91:28-36. [PMID: 31094473 DOI: 10.26442/00403660.2019.04.000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM to assess the diagnostic meaning of cardiac magnetic resonance imaging (CMR) in various clinical forms of myocarditis. MATERIALS AND METHODS 11 (8 men, mean age 32.8±11.1 years) patients (pts), hospitalized with suspected acute coronary syndrome, while an acute myocardial infarction was excluded during the examination (group I); 48 pts (31 men, 43.1±12.7 years), with clinical and instrumental signs of dilated cardiomyopathy (DCM) - group II; and 20 patients (12 men, 39.5±14 years), with episodes of ventricular tachycardia (group III) underwent cardiac magnetic resonance imaging (CMRI). In 38 patients endomyocardial biopsy (EMB) was performed. RESULTS According to EMB, signs of active myocarditis were revealed in 10 (34.5%) group II pts and in 3 (37.5%) group III pts; signs of resolved myocarditis - in 8 (27.6%) patients in group II and in 3 (37.5%); minimal morphological changes - in 11 (37.9%) patients of group II and in 2 (25%) patients of group III. In 9 (81.9%) patients of group I MRI data allowed to establish the diagnosis of acute myocarditis. Signs of active inflammation from MRI data were detected in myocardium 5 (10.4%) in group II pts and 7 (35%) in group III pts. In 22 (45.8%) pts in group II and 10 (50%), CMR data corresponded to the picture of resolved myocarditis. In 21 (43.8%) cases of group II and 3 (15%) of group III, MRI revealed minimal structural changes. In pts with clinical and instrumental signs of DCM and/or ventricular tachycardia MRI allows to identify signs of "active myocarditis" with a sensitivity of 37.5% with a specificity of 83.4%. At the same time, in cases of resolved myocarditis and minimal morphological changes MRI has high sensitivity (70 and 71.5%) and specificity (71.5 and 75%, respectively). CONCLUSION CMR has high diagnostic significance in patients with infarct-like course of myocarditis. In patients with clinical syndrome of dilated cardiomyopathy or arrhythmias, the sensitivity of MRI in detecting active myocarditis is low (37.5%) with high specificity (83.4%). In cases of minimal structural changes in the myocardium and resolved inflammation, CMR is a good alternative to EMB.
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Affiliation(s)
- O V Stukalova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - E M Gupalo
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - P V Chumachenko
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - A N Samko
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - E A Butorova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - R M Shakhnovich
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - N A Mironova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - O Yu Narusov
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - A A Safiullina
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - M A Shariya
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - S P Golitsyn
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - S K Ternovoy
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Moscow, Russia
| | - I E Chazova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
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Rodriguez-Gonzalez M, Sanchez-Codez MI, Lubian-Gutierrez M, Castellano-Martinez A. Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: A retrospective study. World J Clin Cases 2019; 7:548-561. [PMID: 30863755 PMCID: PMC6406197 DOI: 10.12998/wjcc.v7.i5.548] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Myocarditis is an important cause of morbidity and mortality in children, leading to long-term sequelae including chronic congestive heart failure, dilated cardiomyopathy, heart transplantation, and death. The initial diagnosis of myocarditis is usually based on clinical presentation, but this widely ranges from the severe sudden onset of a cardiogenic shock to asymptomatic patients. Early recognition is essential in order to monitor and start supportive treatment prior to the development of severe adverse events. Of note, many cases of fulminant myocarditis are usually misdiagnosed as otherwise minor conditions during the weeks before the unexpected deterioration.
AIM To provide diagnostic clues to make an early recognition of pediatric myocarditis. To investigate early predictors for poor outcomes.
METHODS We conducted a retrospective cross-sectional single-center study from January 2008 to November 2017 at the Pediatric Department of our institution, including children < 18-years-old diagnosed with myocarditis. Poor outcome was defined as the occurrence of any of the following facts: death, heart transplant, persistent left ventricular systolic dysfunction or dilation at hospital discharge (early poor outcome), or after 1 year of follow-up (late poor outcome). We analyzed different clinical features and diagnostic test findings in order to provide diagnostic clues for myocarditis in children. Multivariable stepwise logistic regression analysis was performed using all variables that had been selected by univariate analysis to determine independent factors that predicted a poor early or late outcome in our study population.
RESULTS A total of 42 patients [69% male; median age of 8 (1.5-12) years] met study inclusion criteria. Chest pain (40%) was the most common specific cardiac symptom. Respiratory tract symptoms (cough, apnea, rhinorrhea) (38%), shortness of breath (35%), gastrointestinal tract symptoms (vomiting, abdominal pain, diarrhea) (33%), and fever (31%) were the most common non-cardiac initial complaints. Tachycardia (57%) and tachypnea (52%) were the most common signs on the initial physical exam followed by nonspecific signs of respiratory tract infection (44%) and respiratory distress (35%). Specific abnormal signs of heart failure such as heart murmur (26%), systolic hypotension (24%), gallop rhythm (20%), or hepatomegaly (20%) were less prevalent. Up to 43% of patients presented an early poor outcome, and 16% presented a late poor outcome. In multivariate analysis, an initial left ventricular ejection fraction (LVEF) < 30% remained the only significant predictor for early [odds ratio (OR) (95%CI) = 21 (2-456), P = 0.027) and late [OR (95%CI) = 8 (0.56-135), P = 0.047) poor outcome in children with myocarditis. LVEF correlated well with age (r = 0.51, P = 0.005), days from the initiation of symptoms (r = -0.31, P = 0.045), and N-terminal pro-brain natriuretic peptide levels (r = 0.66, P < 0.001), but not with troponin T (r = -0.05, P = 0.730) or C-reactive protein levels (r = -0.13, P = 0.391). N-terminal pro-brain natriuretic peptide presented a high diagnostic accuracy for LVEF < 30% on echocardiography with an area under curve of 0.931 (95%CI: 0.858-0.995, P < 0.001). The best cut-off point was 2000 pg/mL with a sensitivity of 90%, specificity of 81%, positive predictive value of 60%, and negative predictive value of 96%.
CONCLUSION The diagnosis of myocarditis in children is challenging due to the heterogeneous and unspecific clinical presentation. The presence of LVEF < 30% on echocardiography on admission was the major predictor for poor outcomes. Younger ages, a prolonged course of the disease, and N-terminal pro-brain natriuretic peptide levels could help to identify these high-risk patients.
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30
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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. [PMID: 30740183 DOI: 10.3889/oamjms.2019.010.pmid:30740183;pmcid:pmc6352488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] 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.
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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
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31
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Gannon MP, Schaub E, Grines CL, Saba SG. State of the art: Evaluation and prognostication of myocarditis using cardiac MRI. J Magn Reson Imaging 2019; 49:e122-e131. [DOI: 10.1002/jmri.26611] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 01/14/2023] Open
Affiliation(s)
- Michael P. Gannon
- National Heart, Lung, and Blood InstituteNational Institutes of Health Bethesda Maryland USA
| | - Ebe Schaub
- University of Heidelberg Heidelberg Germany
| | - Cindy L. Grines
- Department of CardiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
| | - Shahryar G. Saba
- Department of CardiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
- Department of RadiologyBarbara and Donald Zucker School of Medicine at Hofstra Northwell Manhasset New York USA
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32
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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.
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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
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Identifying Non-invasive Tools to Distinguish Acute Myocarditis from Dilated Cardiomyopathy in Children. Pediatr Cardiol 2018; 39:1134-1138. [PMID: 29651540 DOI: 10.1007/s00246-018-1867-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Abstract
There is often a diagnostic dilemma in pediatric patients presenting with depressed ventricular function, as myocarditis and dilated cardiomyopathy (DCM) of other etiologies can appear very similar. Accurate identification is critical to guide treatment and to provide families with the most accurate expectation of long-term outcomes. The objective of this study was to identify patterns of clinical presentation and to assess non-invasive measures to differentiate patients with acute myocarditis from other forms of DCM. We identified all children (< 18 years) from our institution with a diagnosis of idiopathic DCM or myocarditis based on endomyocardial biopsy or explant pathology (1996-2015). Characteristics at the time of presentation were compared between patients with a definite diagnosis of myocarditis and those with idiopathic DCM. Data collected included clinical and laboratory data, radiography, echocardiography, and cardiac catheterization data. A total of 58 patients were included in the study; 46 (79%) with idiopathic DCM and 12 (21%) with acute myocarditis. Findings favoring a diagnosis of myocarditis included a history of fever (58 vs. 15%, p = 0.002), arrhythmia (17 vs. 0%, p = 0.003), higher degree of cardiac enzyme elevation, absence of left ventricular dilation (42 vs. 7%, p = 0.002), segmental wall motion abnormalities (58 vs. 13%, p = 0.001), lower left ventricular dimension z-score (3.7 vs. 5.2, p = 0.031), and less severe depression of left ventricular systolic function. There are notable differences between patients with myocarditis and other forms of DCM that can be detected non-invasively at the time of presentation without the need for endomyocardial biopsy. These data suggest that it may be possible to develop a predictive model to differentiate myocarditis from other forms of DCM using non-invasive measures.
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34
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Berner AM, Sharma A, Agarwal S, Al-Sam S, Nathan P. Fatal autoimmune myocarditis with anti-PD-L1 and tyrosine kinase inhibitor therapy for renal cell cancer. Eur J Cancer 2018; 101:287-290. [PMID: 30017380 DOI: 10.1016/j.ejca.2018.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 11/18/2022]
Affiliation(s)
- A M Berner
- Department of Oncology, Mount Vernon Cancer Centre, Northwood HA6 2RN, UK.
| | - A Sharma
- Department of Oncology, Mount Vernon Cancer Centre, Northwood HA6 2RN, UK
| | - S Agarwal
- Department of Histopathology, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage, Hertfordshire SG1 4AB, UK
| | - S Al-Sam
- Princess Alexandra Hospital, Hamstel Road, Harlow, Essex CM20 1QX, UK
| | - P Nathan
- Department of Oncology, Mount Vernon Cancer Centre, Northwood HA6 2RN, UK
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35
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Haouzi A, Ahmed A. 'Clinically suspected myocarditis with pseudoinfarct presentation' complicated with left ventricular aneurysm. BMJ Case Rep 2018; 2018:bcr-2017-222114. [PMID: 29348279 PMCID: PMC5778224 DOI: 10.1136/bcr-2017-222114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2017] [Indexed: 11/04/2022] Open
Abstract
A 51-year-old man presented with chest pain, high troponin level, inflammatory syndrome and ST-segment elevation in the anterior leads. While the transthoracic echocardiogram (TTE) showed anteroseptal hypokinesis and apical akinesis, the coronary angiogram was normal. Cardiac MR demonstrated a typical aspect of myocarditis (multiple areas of mid-myocardial late gadolinium enhancement, sparing the subendocardial layer, along with oedema). The initial diagnosis was clinically suspected myocarditis with pseudoinfarct presentation. However, the short-term evolution was not typical of this syndrome, since an apical transmural scar with aneurysm developed within 2 weeks. Seven years later, the patient remained asymptomatic, while Q waves persisted in anterior leads along with an apical aneurysm on TTE. A transmural myocardial necrosis with aneurysm is an unusual complication of acute myocarditis. The potential mechanisms accounting for the development of these lesions are reviewed, and the clinical implications for the diagnosis and monitoring of acute myocarditis are discussed.
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Affiliation(s)
- Annick Haouzi
- Heart and Vascular Institute, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ahmed Ahmed
- Department of Cardiology, St Bernards Heart and Vascular, Jonesboro, Arkansas, USA
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36
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Assessment of TSPO in a Rat Experimental Autoimmune Myocarditis Model: A Comparison Study between [ 18F]Fluoromethyl-PBR28 and [ 18F]CB251. Int J Mol Sci 2018; 19:ijms19010276. [PMID: 29342117 PMCID: PMC5796222 DOI: 10.3390/ijms19010276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 01/03/2023] Open
Abstract
Overexpression of the 18-kDa translocator protein (TSPO) is closely linked to inflammatory responses in the heart, including myocarditis, which can lead to myocardial necrosis. In vivo assessment of inflammatory responses has enabled the precise diagnosis of myocarditis to improve clinical outcomes. Here, we evaluated TSPO overexpression in a rat model of experimental autoimmune myocarditis (EAM) compared to healthy rats using two TSPO radiotracers, [18F]fluoromethyl-PBR28 ([18F]1) and [18F]CB251 ([18F]2). All radiolabeling methods were successfully applied to an automated module for the reproducible preparation of TSPO radiotracers. Both radiotracers were directly compared in an EAM rat model, as well as in healthy rats to determine whether either radiotracer provides a more promising assessment of in vivo TSPO overexpression. [18F]2 provided more specific TSPO-uptake in the heart of the EAM rats (1.32-fold that of the heart-to-lung uptake ratio versus healthy controls), while [18F]1 did not show a significant difference between the two groups. Histopathological characterization revealed that a prominent positron emission tomography (PET) signal of [18F]2 in the EAM rats corresponded to the presence of a higher density of TSPO compared to the healthy controls. These results suggest that the imidazole[1,2-a]pyridine-based radiotracer [18F]2 is a sensitive tool for noninvasively diagnosing myocarditis related to inflammation of the heart muscle by assessing abnormal TSPO expression.
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Casella M, Dello Russo A, Vettor G, Lumia G, Catto V, Sommariva E, Ribatti V, Biagioli V, Tundo F, Carbucicchio C, Di Biase L, Natale A, Tondo C. Electroanatomical mapping systems and intracardiac echo integration for guided endomyocardial biopsy. Expert Rev Med Devices 2017; 14:609-619. [PMID: 28678556 DOI: 10.1080/17434440.2017.1351875] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION During the past years, endomyocardial biopsy (EMB) has gradually spread into clinical practice. However, the role of EMB in the diagnosis and treatment of cardiovascular diseases remains a controversial issue, especially in the setting of unexplained ventricular arrhythmias. Areas covered: This review describes the methodology of EMB guided by combined use of three-dimensional electroanatomical mapping systems and intracardiac echo and summarizes the classical, fluoroscopy-guided EMB technique. Finally, the personal experience acquired with the 'electrophysiologist-made' integration methodology has been reported. Expert commentary: Since EMB has been considered in the setting of arrhythmogenic cardiomyopathy, myocarditis, cardiac sarcoidosis, drug toxicity, and/or other diseases causing malignant ventricular arrhythmias, the electrophysiologists have started to perform firsthand biopsy. The electrophysiologists introduced the use of electroanatomical mapping systems and intracardiac echo. This new methodology improved significantly biopsy diagnostic yield and allowed to reduce complications.
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Affiliation(s)
- Michela Casella
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Antonio Dello Russo
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Giulia Vettor
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Giuseppe Lumia
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Valentina Catto
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Elena Sommariva
- b Vascular Biology and Regenerative Medicine Unit , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Valentina Ribatti
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Viviana Biagioli
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Fabrizio Tundo
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Corrado Carbucicchio
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
| | - Luigi Di Biase
- c Texas Cardiac Arrhythmia Institute at St David's Medical Center , Austin , TX , USA.,d Albert Einstein College of Medicine at Montefiore Hospital , New York , NY , USA.,e Department of Cardiology , University of Foggia , Foggia , Italy.,f Department of Biomedical Engineering , University of Texas , Austin , TX , USA
| | - Andrea Natale
- c Texas Cardiac Arrhythmia Institute at St David's Medical Center , Austin , TX , USA.,f Department of Biomedical Engineering , University of Texas , Austin , TX , USA.,g Division of Cardiology , Stanford University , Palo Alto , CA , USA.,h Case Western Reserve University , Cleveland , OH , USA
| | - Claudio Tondo
- a Cardiac Arrhythmia Research Centre , Centro Cardiologico Monzino IRCCS , Milan , Italy
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Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH. Clinical characteristics and outcomes of patients with myocarditis mimicking ST-segment elevation myocardial infarction: Analysis of a case series. Medicine (Baltimore) 2017; 96:e6863. [PMID: 28489781 PMCID: PMC5428615 DOI: 10.1097/md.0000000000006863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Acute myocarditis mimicking ST-segment elevation myocardial infarction (STEMI) is highly deceptive for an accurate diagnosis, and a systematic study is lacking with regard to the clinical features and prognosis of this distinct clinical entity.Patients with suspected STEMI and eventually diagnosed with myocarditis by cardiac magnetic resonance (CMR) from January 2012 to April 2016 at Fuwai Hospital were identified by reviewing medical records and electronic databases. Follow-up was conducted by clinical visits and phone contacts in a median duration of 17 months.A total of 18 patients were included in the study, with 17 males and 1 female. They were relatively young, and their mean age was 30.8 years. 94.4% of the patients had a high prevalence of infectious prodrome, and inflammatory biomarkers were notably elevated in all patients. Late gadolinium enhancement on CMR was detected in 13 patients. Three patients underwent fulminant course, and left ventricular ejection fraction (LVEF) <45% on admission occurred in 3 patients. The median LVEF improved from 59% on admission to 65% at discharge (P <.001), and none developed cardiac insufficiency, heart transplantation, or death during a median follow-up of 17 months.Myocarditis mimicking STEMI is featured by young age and an existence of flu-like prodrome. CMR benefits the differential diagnosis of this unique clinical entity. Notably, patients with myocarditis mimicking STEMI had a favorable prognosis, and establishing an accurate diagnosis is crucial to avoid unreasonable treatments for them.
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Hékimian G, Franchineau G, Bréchot N, Schmidt M, Nieszkowska A, Besset S, Luyt CE, Combes A. Diagnostic et prise en charge des myocardites. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Caforio ALP, Malipiero G, Marcolongo R, Iliceto S. Clinically suspected myocarditis with pseudo-infarct presentation: the role of endomyocardial biopsy. J Thorac Dis 2017; 9:423-427. [PMID: 28449434 DOI: 10.21037/jtd.2017.03.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alida L P Caforio
- Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giacomo Malipiero
- Department of Medicine, Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | - Renzo Marcolongo
- Department of Medicine, Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Abstract
Acute myocarditis must be considered in patients with recent onset of cardiac failure or arrhythmia. Fulminant myocarditis is a distinct entity characterized by sudden onset of severe congestive heart failure or cardiogenic shock, usually following a flu-like illness, parvovirus B19, human herpesvirus 6, coxsackie virus and adenovirus being the most frequently viruses responsible for the disease. In this setting, early recognition of patients rapidly progressing to refractory cardiac failure and their immediate transfer to a medical-surgical center experienced in mechanical circulatory support is warranted. Treatment of acute myocarditis relies on conventional heart failure therapy. Immunosuppression of autoreactive myocarditis or immuno-stimulants such as interferons for chronic viral myocarditis could be of interest but their potential therapeutic role requires further investigation.
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Affiliation(s)
- G Hékimian
- Service de réanimation médicale, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - A Combes
- Service de réanimation médicale, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
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Woudstra L, Biesbroek PS, Emmens RW, Heymans S, Juffermans LJ, van Rossum AC, Niessen HWM, Krijnen PAJ. Lymphocytic myocarditis occurs with myocardial infarction and coincides with increased inflammation, hemorrhage and instability in coronary artery atherosclerotic plaques. Int J Cardiol 2017; 232:53-62. [PMID: 28087177 DOI: 10.1016/j.ijcard.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/28/2016] [Accepted: 01/04/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Although lymphocytic myocarditis (LM) clinically can mimic myocardial infarction (MI), they are regarded as distinct clinical entities. However, we observed a high prevalence (32%) of recent MI in patients diagnosed post-mortem with LM. To investigate if LM changes coronary atherosclerotic plaque, we analyzed in autopsied hearts the inflammatory infiltrate and stability in coronary atherosclerotic lesions in patients with LM and/or MI. METHODS The three main coronary arteries were isolated at autopsy of patients with LM, with MI of 3-6h old, with LM and MI of 3-6h old (LM+MI) and controls. In tissue sections of atherosclerotic plaque-containing coronary segments inflammatory infiltration, plaque stability, intraplaque hemorrhage and thrombi were determined via (immuno)histological criteria. RESULTS In tissue sections of those coronary segments the inflammatory infiltrate was found to be significantly increased in patients with LM, LM+MI and MI compared with controls. This inflammatory infiltrate consisted predominantly of macrophages and neutrophils in patients with only LM or MI, of lymphocytes in LM+MI and MI patients and of mast cells in LM+MI patients. Moreover, in LM+MI and MI patients this coincided with an increase of unstable plaques and thrombi. Finally, LM and especially MI and LM+MI patients showed significantly increased intraplaque hemorrhage. CONCLUSIONS This study demonstrates prevalent co-occurrence of LM with a very recent MI at autopsy. Moreover, LM was associated with remodeling and inflammation of atherosclerotic plaques indicative of plaque destabilization pointing to coronary spasm, suggesting that preexistent LM, or its causes, may facilitate the development of MI.
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Affiliation(s)
- Linde Woudstra
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands.
| | - P Stefan Biesbroek
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands; ICIN, Inter-university Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Reindert W Emmens
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands
| | - Stephane Heymans
- Center for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), University Hospital Maastricht, Maastricht, The Netherlands
| | - Lynda J Juffermans
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands
| | - Albert C van Rossum
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands
| | - Hans W M Niessen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, The Netherlands
| | - Paul A J Krijnen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands
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Diffuse Gallium-67 Accumulation in the Left Atrial Wall Detected Using SPECT/CT Fusion Images. Case Rep Radiol 2016; 2016:6374584. [PMID: 28097031 PMCID: PMC5206417 DOI: 10.1155/2016/6374584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/25/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022] Open
Abstract
Gallium-67 scintigraphy is useful for detecting active inflammation. We show a 66-year-old female patient with atrial fibrillation and diffuse thickening of the left atrial wall due to acute myocarditis, who presented diffuse abnormal accumulation of gallium-67 in the left atrium on single photon emission computed tomography/computed tomography (SPECT/CT) fusion images. In the second gallium-67 scan 2 months after the first scintigraphy, the abnormal accumulation in the heart was no longer visible. Gallium-67 SPECT/CT images helped understanding the disease condition that temporary inflammation in the left atrium caused atrial fibrillation.
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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.
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45
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Medico-legal perspectives on sudden cardiac death in young athletes. Int J Legal Med 2016; 131:393-409. [PMID: 27654714 DOI: 10.1007/s00414-016-1452-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/08/2016] [Indexed: 01/11/2023]
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Irina P, Alina S, Constantin ȘR. To Be or Not to Be … Acute Coronary Syndrome. ACTA MEDICA MARISIENSIS 2016. [DOI: 10.1515/amma-2016-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction: The association between ST segment abnormalities, elevated cardiac enzymes, and chest pain is usually a marker of acute coronary injury. However, certain other pathologies can sometimes mimic acute coronary syndromes.
Case report: A 40-year-old Caucasian male, former smoker, with no other cardiovascular risk factors, presented to the Emergency Department for typical ischemic, prolonged chest pain. The ECG demonstrated inverted T waves in leads I, II, aVL, and V3 to V6. The patient presented high cardiac necrosis markers (troponin I 2.65 ng/ml). Based on these findings, the case was interpreted as non-ST segment elevation myocardial infarction, but coronary angiography excluded the presence of significant coronary lesions. The ventriculography showed an efficient left ventricle, with mild hypokinesia of the two apical thirds of the anterior left ventricular wall. Cardiac magnetic resonance imaging demonstrated areas of hypersignal on the T2-weighted imaging sequence in the left ventricular myocardium, suggestive for acute myocarditis. The patient was started on antiplatelet, beta-blocker, and angiotensin converting enzyme inhibitor, with favorable evolution.
Conclusion: This case underlines the polymorphic appearance of acute myocarditis, which can often mimic an acute coronary event.
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Affiliation(s)
- Pintilie Irina
- Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Scridon Alina
- Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Șerban Răzvan Constantin
- Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
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Zarka S, Bouleti C, Arangalage D, Chopra H, Chillon S, Henry-Feugeas MC, Abtan J, Juliard JM, Iung B, Vahanian A, Laissy JP, Ou P. Usefulness of Subepicardial Hyperemia on Contrast-Enhanced First-Pass Magnetic Resonance Perfusion Imaging for Diagnosis of Acute Myocarditis. Am J Cardiol 2016; 118:440-5. [PMID: 27296557 DOI: 10.1016/j.amjcard.2016.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 11/16/2022]
Abstract
Hyperemia is a major criterion for the diagnosis of acute myocarditis on cardiac magnetic resonance imaging but its assessment is challenging and time consuming. We evaluated the usefulness of the contrast-enhanced first-pass perfusion (FPP) on magnetic resonance imaging for detecting subepicardial hyperemia in acute myocarditis. Forty-seven consecutive patients (mean age: 42 ± 15.6 years; 35 men) with a definite diagnosis of acute myocarditis according to the state-of-the-art guidelines were included and compared with 16 control subjects. FPP was evaluated by 2 blinded observers and compared with the reference late gadolinium enhancement. Detection of hyperemia was performed on both qualitative and quantitative methods. Relative increased signal intensity (SI) in the subepicardial hyperemic layer was measured with SI ratio (SI of the subepicardial layer/SI of the immediately adjacent subendocardial layer). Twenty-four patients (51%) with acute myocarditis exhibited subepicardial hyperemia, detected with a good interobserver reproducibility (kappa coefficient: 0.75). The SI in the myocardium of myocarditis patients was increased compared with controls (1.08 ± 0.03 vs 0.945 ± 0.04, p = 0.03) and the SI in myocarditis patients with hyperemia compared with those without hyperemia (1.22 ± 0.04 vs 0.94 ± 0.04, p <0.0001). Sensitivity, specificity, positive predictive, and negative predictive values of FPP for detecting hyperemia were 85%, 94%, 85%, and 93%, respectively. In conclusion, contrast-enhanced first-pass magnetic resonance imaging is a fast and useful method for assessing myocardial hyperemia in patients with acute myocarditis.
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Affiliation(s)
- Samuel Zarka
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Claire Bouleti
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Dimitri Arangalage
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Houzefa Chopra
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Sylvie Chillon
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | | | - Jérémie Abtan
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Jean-Michel Juliard
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Bernard Iung
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Jean-Pierre Laissy
- Paris-Diderot University, DHU FIRE, Paris, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Phalla Ou
- Paris-Diderot University, DHU FIRE, Paris, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148 Bichat Hospital, Paris, France.
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Gibson R, Delaune J, Szady A, Markham M. Suspected autoimmune myocarditis and cardiac conduction abnormalities with nivolumab therapy for non-small cell lung cancer. BMJ Case Rep 2016; 2016:bcr-2016-216228. [PMID: 27440853 DOI: 10.1136/bcr-2016-216228] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Checkpoint inhibitors such as nivolumab represent a novel class of agents that are being increasingly used in the treatment of various cancers. Their toxicities represent unique challenges to the oncologists prescribing them, patients' primary care physicians and other specialists who may encounter these patients during consultations. It is important for physicians to remain vigilant and include autoimmune toxicities in the list of potential differential diagnoses in patients receiving novel cancer therapeutics who present with unusual toxicities. We report the unusual case of a 68-year-old woman with advanced lung cancer on the novel chemotherapeutic Nivolumab whom we suspect developed autoimmune myocarditis with significant cardiac conduction disease as an unintended, and as of yet unrecognised, side effect from this medication.
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Affiliation(s)
- Robert Gibson
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Jess Delaune
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Anita Szady
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Merry Markham
- Department of Oncology, University of Florida, Gainesville, Florida, USA
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Jbeli AH, Anuwatworn A, Petrasko MS. Myocarditis mimicking acute coronary syndrome: the role of cardiac magnetic resonance imaging and immunoglobulin therapy. Am J Emerg Med 2015; 33:1717.e3-4. [DOI: 10.1016/j.ajem.2015.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 03/19/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022] Open
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