Prevalence of cardiotropic viruses in adults with clinically suspected myocarditis in South Africa

Acute myocarditis and haemoptysis in an adult with human bocavirus monoinfection: a case report

Background

Bocavirus monoinfection-related acute myocarditis is an aetiology that has rarely been described in the literature.

Case summary

A 36-year-old male, with no significant medical history, presented to the emergency department with a 4-day history of dyspnoea, haemoptysis, left-sided chest pain, and high-grade pyrexia. The initial investigations revealed a raised troponin T, raised C-reactive protein, and a normal electrocardiogram. A comprehensive microbiological and virological work-up (testing for 14 viruses and bacteria) detected human bocavirus (HBoV) DNA monoinfection. Cardiac magnetic resonance imaging showed left ventricular ejection fraction of 48%, with subepicardial late gadolinium enhancement. Other imaging modalities (chest X-ray, echocardiography, computed tomography pulmonary angiography, and bronchoscopy) revealed no other causative pathology. The patient was treated with anti-inflammatory medications and left ventricle remodelling therapy. He had a good clinical outcome. Moreover, a collateral history revealed that the patient's infant had presented with a severe respiratory illness, which was felt to be of viral aetiology, several days prior to the patient's own onset of symptoms.

Discussion

To our knowledge, this is the fourth case of HBoV-related acute myocarditis in an immunocompetent adult. This case also displays new clinical features for HBoV infection-haemoptysis, high-grade pyrexia, and a potential for vertical transmission from infants.

Global burden of myocarditis in youth and middle age (1990-2019): A systematic analysis of the disease burden and thirty-year forecast

BACKGROUND

Myocarditis is increasingly recognized as a critical health issue, particularly among youth and middle-aged populations. This study aims to analyze the global burden and trends of myocarditis in these age groups to emphasize the need for region-specific prevention and treatment strategies.

METHODS

Using data from the Global Burden of Disease (GBD) study (1990-2019), we evaluated the age-standardized rates (ASR) of myocarditis in individuals aged 10 to 54 years. We calculated average annual percentage changes (AAPC) and estimated annual percentage changes (EAPC). Additionally, we examined the correlation between myocarditis incidence and the Human Development Index (HDI) and Socio-demographic Index (SDI). Age and sex trends in myocarditis were analyzed, and Bayesian age-period-cohort (BAPC) models were used to forecast prevalence trends up to 2050.

RESULTS

The High-income Asia Pacific region had the highest ASR of myocarditis, while North Africa and the Middle East had the lowest. North Africa and the Middle East also experienced the fastest average annual growth in ASR, whereas High-income North America saw the most significant decline. Correlational analysis showed that countries with a high SDI exhibited higher myocarditis ASR. The burden of myocarditis was greater among males than females, with this disparity increasing with age. Projections indicate a stable trend in the incidence of myocarditis among the youth and middle-aged population up to 2050, although the total number of cases is expected to rise.

CONCLUSION

Our study reveals a significant upward trend in myocarditis among youth and middle-aged populations, highlighting the urgency for early monitoring and preventative strategies.

Infectious factors in myocarditis: a comprehensive review of common and rare pathogens

BACKGROUND

Myocarditis is a significant health threat today, with infectious agents being the most common cause. Accurate diagnosis of the etiology of infectious myocarditis is crucial for effective treatment.

MAIN BODY

Infectious myocarditis can be caused by viruses, prokaryotes, parasites, and fungi. Viral infections are typically the primary cause. However, some rare opportunistic pathogens can also damage heart muscle cells in patients with immunodeficiencies, neoplasms and those who have undergone heart surgery.

CONCLUSIONS

This article reviews research on common and rare pathogens of infectious myocarditis, emphasizing the complexity of its etiology, with the aim of helping clinicians make an accurate diagnosis of infectious myocarditis.

Viral cardiovascular surgical diseases: global burdens, challenges and opportunities

Globally, more than one billion people are vulnerable to neglected tropical diseases, many of which have viral origins and cardiovascular implications. Access to cardiovascular care is limited in countries where these conditions are endemic. Six billion people lack access to safe, timely and affordable cardiac surgical care, whereby over 100 countries and territories lack a single cardiac surgeon. Moreover, while clinically unique, the surgical consequences of neglected cardiovascular diseases with viral origins have been poorly described in the current literature. This review provides an overview of the global burden of viral cardiovascular disease, describes access to cardiac surgical care in regions where these conditions are endemic, and further highlights surgical consequences and considerations to manage patients requiring cardiac surgical care.

Advancing Precision Medicine in Myocarditis: Current Status and Future Perspectives in Endomyocardial Biopsy-Based Diagnostics and Therapeutic Approaches

The diagnosis and specific and causal treatment of myocarditis and inflammatory cardiomyopathy remain a major clinical challenge. Despite the rapid development of new imaging techniques, endomyocardial biopsies remain the gold standard for accurate diagnosis of inflammatory myocardial disease. With the introduction and continued development of immunohistochemical inflammation diagnostics in combination with viral nucleic acid testing, myocarditis diagnostics have improved significantly since their introduction. Together with new technologies such as miRNA and gene expression profiling, quantification of specific immune cell markers, and determination of viral activity, diagnostic accuracy and patient prognosis will continue to improve in the future. In this review, we summarize the current knowledge on the pathogenesis and diagnosis of myocarditis and inflammatory cardiomyopathies and highlight future perspectives for more in-depth and specialized biopsy diagnostics and precision, personalized medicine approaches.

Sex and gender differences in myocarditis and dilated cardiomyopathy: An update

In the past decade there has been a growing interest in understanding sex and gender differences in myocarditis and dilated cardiomyopathy (DCM), and the purpose of this review is to provide an update on this topic including epidemiology, pathogenesis and clinical presentation, diagnosis and management. Recently, many clinical studies have been conducted examining sex differences in myocarditis. Studies consistently report that myocarditis occurs more often in men than women with a sex ratio ranging from 1:2-4 female to male. Studies reveal that DCM also has a sex ratio of around 1:3 women to men and this is also true for familial/genetic forms of DCM. Animal models have demonstrated that DCM develops after myocarditis in susceptible mouse strains and evidence exists for this progress clinically as well. A consistent finding is that myocarditis occurs primarily in men under 50 years of age, but in women after age 50 or post-menopause. In contrast, DCM typically occurs after age 50, although the age that post-myocarditis DCM occurs has not been investigated. In a small study, more men with myocarditis presented with symptoms of chest pain while women presented with dyspnea. Men with myocarditis have been found to have higher levels of heart failure biomarkers soluble ST2, creatine kinase, myoglobin and T helper 17-associated cytokines while women develop a better regulatory immune response. Studies of the pathogenesis of disease have found that Toll-like receptor (TLR)2 and TLR4 signaling pathways play a central role in increasing inflammation during myocarditis and in promoting remodeling and fibrosis that leads to DCM, and all of these pathways are elevated in males. Management of myocarditis follows heart failure guidelines and there are currently no disease-specific therapies. Research on standard heart failure medications reveal important sex differences. Overall, many advances in our understanding of the effect of biologic sex on myocarditis and DCM have occurred over the past decade, but many gaps in our understanding remain. A better understanding of sex and gender effects are needed to develop disease-targeted and individualized medicine approaches in the future.

Monkeypox-Induced Myocarditis: A Systematic Review

Monkeypox virus has emerged in different parts of the world with varying clinical symptoms and outcomes. To date, only a few studies have reported cardiac manifestations among monkeypox-infected patients. We aim to systematically evaluate the symptoms, imaging findings, management, and outcomes among monkeypox-induced myocarditis patients. We conducted a systematic literature search in PubMed, Embase, and Scopus from inception till 5th January 2023 by using predefined MESH terms and "AND" and "OR." The following search terms were used: "monkeypox virus" AND "myocarditis." A total of 6 studies with 9 monkeypox-induced myocarditis patients were included in this analysis. The mean age of patients was 33.6 years, with all being male patients. The most common symptoms were fever (89%) and chest pain (100%). Electrocardiogram findings showed 44% of patients had ST-elevation, and 22% had sinus tachycardia. The echocardiographic findings show a mean ejection fraction of 52.14%, while 57% of patients had preserved ejection fraction, and 67% had normal wall motion. Cardiac magnetic resonance findings show 40% of patients had late gadolinium enhancement, and 40% had edema. Management of patients was primarily supportive (33%), and 33% of patients were administered Beta blockers and ACE inhibitors. Overall all patients survived with a good prognosis. Our study's findings show that all cases were reported among male patients with the most common symptoms of chest pain. The overall prognosis was good, with no mortality reported. Infected patients complaining of chest pain should not be ignored, and proper investigation of myocarditis must be considered.

Clinical course, viral etiology, and the diagnostic workup for patients with suspected myocarditis: a single-center prospective study

BACKGROUND

Myocarditis is a highly heterogeneous disorder with a challenging diagnostic work-up. We aimed to focus on the possible diagnostic workup for this condition in settings where endomyocardial biopsy as a gold standard is not always feasible, detect the etiologic cardiotropic viruses in our locality, and follow the clinical course in patients admitted with clinically suspected myocarditis.

METHODS

This is a prospective observational study. We recruited patients with clinically suspected myocarditis presenting at a university hospital from October 1st, 2020 until March 31st, 2021. All Patients had a diagnostic coronary angiography and were included only if they had a non-obstructive coronary artery disease. All patients also had cardiac magnetic resonance imaging (CMR) with contrast. Sera were obtained from all suspected patients for detection of antibodies against viruses using enzyme-linked immunosorbent assay, and viral genomes using polymerase chain reaction (PCR), and reverse transcription-PCR. Endomyocardial biopsy was done for patients with a typical CMR picture of myocarditis.

RESULTS

Out of 2163 patients presenting to the hospital within the 6 months, only 51 met the inclusion criteria. Males represented 73%, with a mean age of 39 ± 16 years. CMR showed an ischemic pattern in 4 patients and thus they were excluded. We classified patients into two categories based on CMR results: group A (CMR-positive myocarditis), 12 patients (25.5%), and group B (CMR-negative myocarditis), 35 (74.5%) patients. On serological analysis, 66% of patients (n = 31/47) showed antibodies against the common cardiotropic viruses. Parvovirus B19 IgM in 22 patients (47%) and coxsackievirus IgM in 16 (34%) were the most observed etiologies. Regarding the outcome, 42.5% of patients recovered left ventricular ejection fraction and three patients died at 6 months' clinical follow-up.

CONCLUSION

Patients with Clinically suspected myocarditis represented 2.2% of total hospital admissions in 6 months. CMR is only a good positive test for the diagnosis of acute myocarditis. Parvovirus B19 and coxsackievirus were the most common pathogens in our locality.

TRIAL REGISTRATION

Clinical trial registration no., NCT04312490; first registration: 18/03/2020. First recruited case 01/10/2020. URL: https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S0009O3D&selectaction=Edit&uid=U0002DVP&ts=2&cx=9zdfin .