Myocarditis Presenting as Sudden Death in Infants and Children: A Single Centre Analysis by ESGFOR Study Group

Cardiovascular-related death in infancy and childhood: a clinicopathological study of two referral institutions in England

To review post-mortem findings among deaths presenting as sudden and/or unexpected deaths in two centers in the UK during a 16-year period in order to identify those related to cardiovascular conditions. The post-mortem databases of two tertiary referral institutions were searched, and all reports were reviewed. Histological features and results of ancillary investigations were noted. All cases of sudden and/or unexpected cardiac deaths (SCD) between 2003 and 2018 were identified. The study was PRISMA compliant and approved by clinical governance. 68/1129 cases of SCD (6.0%) were identified in one center and 83/753 cases (11%) in the other. These 151 cases constituted the study cohort. The mean annual incidence of SCD was 0.3 per 100,000 persons/annum. The three most prevalent groups of cardiac pathology were cardiac malformations (51/151; 33.8%), cardiomyopathies (32/151; 21.2%), and myocarditis (31/151; 20.5%). Mean age at death was 3.4 years. Prematurity was predominantly associated with deaths related to cardiac malformations (p < 0.001). Symptoms had been present for a mean of 3.8, 3.0, and 3.5 days before death for myocarditis, cardiomyopathy, and cardiac malformations/complications post-surgery. This retrospective comparative study represents the largest autopsy series of SCD in infants and children in the UK. Some entities are very infrequent. Several diseases could have been identified earlier in life allowing for the possibility of intervention. Limitation includes the retrospective nature of the study and that, as arrhythmogenic gene mutations are not yet routinely performed in unexplained deaths, the incidence of SCD in infants and children is most likely underestimated.

Forensic Microbiology: When, Where and How

Forensic microbiology is a relatively new discipline, born in part thanks to the development of advanced methodologies for the detection, identification and characterization of microorganisms, and also in relation to the growing impact of infectious diseases of iatrogenic origin. Indeed, the increased application of medical practices, such as transplants, which require immunosuppressive treatments, and the growing demand for prosthetic installations, associated with an increasing threat of antimicrobial resistance, have led to a rise in the number of infections of iatrogenic origin, which entails important medico-legal issues. On the other hand, the possibility of detecting minimal amounts of microorganisms, even in the form of residual traces (e.g., their nucleic acids), and of obtaining gene and genomic sequences at contained costs, has made it possible to ask new questions of whether cases of death or illness might have a microbiological origin, with the possibility of also tracing the origin of the microorganisms involved and reconstructing the chain of contagion. In addition to the more obvious applications, such as those mentioned above related to the origin of iatrogenic infections, or to possible cases of infections not properly diagnosed and treated, a less obvious application of forensic microbiology concerns its use in cases of violence or violent death, where the characterization of the microorganisms can contribute to the reconstruction of the case. Finally, paleomicrobiology, e.g., the reconstruction and characterization of microorganisms in historical or even archaeological remnants, can be considered as a sister discipline of forensic microbiology. In this article, we will review these different aspects and applications of forensic microbiology.

Paradigm shift in myocarditis treatment

Although most cases of myocarditis are self-limiting with a gradual improvement in cardiac function, the involvement of myocarditis in sudden cardiac death among children and young adults remains substantial, with rates of 3-17 % and 8.6-12 %, respectively. Moreover, the risk of developing chronic dilated cardiomyopathy ranges from 21 % to 30 % in all cases confirmed by biopsy. Current therapeutic strategies for myocarditis and its complications range from standard supportive care for heart failure and arrhythmias to etiologically oriented, case-based therapeutic options. For example, immunosuppression is indicated only in certain forms of acute myocarditis with clinical or endomyocardial biopsy evidence of immune checkpoint inhibitor-induced myocarditis and autoimmune diseases, including giant cell myocarditis, eosinophilic myocarditis, vasculitis, or cardiac sarcoidosis. However, our views on myocarditis treatment have changed considerably over the past two decades, thanks to the emergence of regenerative cells/tissues as well as drug and gene delivery systems. Cell-based therapies are now growing in popularity in any field of medicine. Studies evaluating the therapeutic efficacy of different stem cells in the treatment of acute myocarditis and its chronic complications have shown that although the experimental characteristics varied from study to study, in general, these strategies reduced inflammation and myocardial fibrosis while preventing myocarditis-induced systolic dysfunction and adverse remodeling in animal models.

Quantitative analysis of respiratory viral distribution in forensic autopsy cases

Respiratory viruses can cause fatal systemic infections; therefore, post-mortem diagnosis is essential in forensic autopsy cases. However, little is known regarding the distribution of respiratory viruses in the body. In this study, we investigated the anatomical distribution of respiratory viruses in 48 forensic autopsy cases suspected of viral infections at our institute. Fast Track Diagnostics (FTD) Respiratory Pathogens 21 was used as a screening test for 20 respiratory viruses in nasopharyngeal swabs. In cases with positive results for virus detection by the screening test, the detected viruses were quantified in body fluid and organ specimens by virus-specific real-time reverse transcription polymerase chain reaction (RT-PCR) and digital PCR. Viruses were detected in 33 cases, with the viral distribution and load differing among the cases. Since various respiratory viruses were detected from the nasopharyngeal swab and its viral load was higher than those of other body fluid specimens, the nasopharyngeal swab was suggested as a useful specimen for the post-mortem detection of respiratory viruses. Viruses were detected in almost all specimens including the serum in six cases. Considering the viral distribution in the body, pathological findings, and ante-mortem symptoms, these cases were presumed to be systemically infected, having died in the acute infection phase. In conclusion, the anatomical distribution of respiratory viruses can help indicate ante-mortem systemic conditions and the cause of death.

From Streptococcal Pharyngitis/Tonsillitis to Myocarditis: A Systematic Review

(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.

Fulminant Myocardial Involvement in Neonatal Echovirus-induced Sepsis. Two Autopsy Cases

Group-B Enteroviruses, such as Echoviruses, are a common cause of infections in neonates but fatal myocarditis during Echovirus-induced sepsis have been rarely reported. We report on 2 cases of neonatal Echovirus-related sepsis with myocarditis. Fatal cardiorespiratory failure occurred in both cases. Autopsies and thorough histologic and microbiologic investigations evidenced Echoviruses 5- and 11-induced myocarditis as the cause of death.