New-Onset Myocarditis in an Immunocompetent Adult with Acute Metapneumovirus Infection

A Case Report of Sepsis-Induced Dilated Cardiomyopathy Secondary to Human Metapneumovirus Infection

Sepsis is a medical emergency that describes the body's systemic immunological response to an infectious process that can lead to end-stage organ dysfunction and death. Sepsis-induced cardiomyopathy (SICM) is an increasingly recognized form of transient cardiac dysfunction characterized by left ventricular dilation, depressed ejection fraction, and recovery in 10 days without cardiac-related medical intervention. Injury to the myocardium by inflammatory cytokines has been proposed as one of the main causative mechanisms. Human metapneumovirus (hMPV) is a paramyxovirus and a common cause of respiratory tract infection that has been reported to modulate chemical mediators that produce inflammatory cytokines. Extra-pulmonary cardiac complications of hMPV have been reported; but literature on SICM associated with hMPV are very rare. We describe a case of a 43-year-old male with no known cardiac history diagnosed with SICM associated with hMPV. His sepsis was managed in the intensive care unit, and his heart ejection fraction improved within 10 days without the initiation of guideline-directed medical therapy.

The knowns and unknowns of cardiac autoimmunity in viral myocarditis

Myocarditis can result from various infectious and non-infectious causes that can lead to dilated cardiomyopathy (DCM) and heart failure. Among the infectious causes, viruses are commonly suspected. But the challenge is our inability to demonstrate infectious viral particles during clinical presentations, partly because by that point, the viruses would have damaged the tissues and be cleared by the immune system. Therefore, viral signatures such as viral nucleic acids and virus-reactive antibodies may be the only readouts pointing to viruses as potential primary triggers of DCM. Thus, it becomes hard to explain persistent inflammatory infiltrates that might occur in individuals affected with chronic myocarditis/DCM manifesting myocardial dysfunctions. In these circumstances, autoimmunity is suspected, and antibodies to various autoantigens have been demonstrated, suggesting that immune therapies to suppress the autoimmune responses may be necessary. From this perspective, we endeavoured to determine whether or not the known viral causes are associated with development of autoimmune responses to cardiac antigens that include both cardiotropic and non-cardiotropic viruses. If so, what their nature and significance are in developing chronic myocarditis resulting from viruses as primary triggers.

First Case of Acute Myocarditis Caused by Metapneumovirus in an Immunocompromised 14-year-old Girl

Background

Human metapneumovirus (hMPV) is a paramyxovirus, well known as a causative agent of respiratory tract infections. Non-respiratory manifestations, including cardiac impairments, remain rare. Only two cases of myocarditis caused by hMPV have been described in adults.

Case description

We present the case of a 14-year-old female suffering from Burkitt leukemia and diagnosed with severe myocarditis caused by hMPV, based on results from real-time polymerase chain reaction (RT-PCR) and magnetic resonance imaging (MRI). She was successfully treated by venoarterial extracorporeal membrane oxygenation and intravenous immunoglobulins. She was discharged from pediatric intensive care unit (PICU) 3 weeks later.

Conclusion

This is the first pediatric case of hMPV myocarditis requiring venoarterial extracorporeal membrane oxygenation.

How to cite this article

Makhlouf A, Peipoch L, Duport P, Darrieux E, Reguerre Y, Ramful D, et al. First Case of Acute Myocarditis Caused by Metapneumovirus in an Immunocompromised 14-year-old Girl. Indian J Crit Care Med 2022;26(6):745–747.

Inhibition of Human Metapneumovirus Binding to Heparan Sulfate Blocks Infection in Human Lung Cells and Airway Tissues

Human metapneumovirus (HMPV), a recently discovered paramyxovirus, infects nearly 100% of the world population and causes severe respiratory disease in infants, the elderly, and immunocompromised patients. We previously showed that HMPV binds heparan sulfate proteoglycans (HSPGs) and that HMPV binding requires only the viral fusion (F) protein. To characterize the features of this interaction critical for HMPV binding and the role of this interaction in infection in relevant models, we utilized sulfated polysaccharides, heparan sulfate mimetics, and occluding compounds. Iota-carrageenan demonstrated potent anti-HMPV activity by inhibiting binding to lung cells mediated by the F protein. Furthermore, analysis of a minilibrary of variably sulfated derivatives of Escherichia coli K5 polysaccharide mimicking the HS structure revealed that the highly O-sulfated K5 polysaccharides inhibited HMPV infection, identifying a potential feature of HS critical for HMPV binding. The peptide dendrimer SB105-A10, which binds HS, reduced binding and infection in an F-dependent manner, suggesting that occlusion of HS at the target cell surface is sufficient to prevent infection. HMPV infection was also inhibited by these compounds during apical infection of polarized airway tissues, suggesting that these interactions take place during HMPV infection in a physiologically relevant model. These results reveal key features of the interaction between HMPV and HS, supporting the hypothesis that apical HS in the airway serves as a binding factor during infection, and HS modulating compounds may serve as a platform for potential antiviral development.

IMPORTANCE

Human metapneumovirus (HMPV) is a paramyxovirus that causes respiratory disease worldwide. It has been previously shown that HMPV requires binding to heparan sulfate on the surfaces of target cells for attachment and infection. In this study, we characterize the key features of this binding interaction using heparan sulfate mimetics, identify an important sulfate modification, and demonstrate that these interactions occur at the apical surface of polarized airway tissues. These findings provide insights into the initial binding step of HMPV infection that has potential for antiviral development.