Abstract
Background: Acute heart failure (AHF) is the major cause of death in children with severe enterovirus 71 (EV71) infection. This study aimed to report our clinical experience with EV71-related AHF, as well as to discuss its pathogenesis and relationship to Takotsubo syndrome (TTS).Methods: A total 27 children with EV71-related AHF between 1998 and 2018 were studied. The TTS diagnosis was based on the International Takotsubo Diagnostic Criteria.Results: Acute heart failure-related early death occurred in 10 (37%) of the patients. Sinus tachycardia, systemic hypertension, and pulmonary edema in 100, 85, and 81% of the patients, respectively, preceded AHF. Cardiac biomarkers were significantly increased in most patients. The main echocardiographic findings included transient and reversible left ventricular (LV) regional wall motion abnormality (RWMA) with apical ballooning. High concentrations of catecholamines either preceded or coexisted with AHF. Myocardial pathology revealed no evidence of myocarditis, which was consistent with catecholamine-induced cardiotoxic damage. Patients with EV71-related AHF who had received close monitoring of their cardiac function, along with early intervention involving extracorporeal life support (ECLS), had a higher survival rate (82 vs. 30%, p = 0.013) and better neurological outcomes (59 vs. 0%, p = 0.003).Conclusion: EV 71-related AHF was preceded by brain stem encephalitis-related hypercatecholaminemia, which resulted in a high mortality rate. Careful monitoring is merited so that any life-threatening cardiogenic shock may be appropriately treated. In view of the similarities in their clinical manifestations, natural course direction, pathological findings, and possible mechanisms, TTS and EV71-related AHF may represent the same syndrome. Therefore, we suggest that EV71-related AHF could constitute a direct causal link to catecholamine-induced secondary TTS.
Highlights
Most children infected by enterovirus 71 (EV71) develop either hand-foot-mouth disease (HFMD) or herpetic angina
Severe EV71 infection with acute heart failure (AHF) preceded by brain stem encephalitis-related hypercatecholaminemia has a high mortality rate
Enterovirus 71-related hypercatecholaminemia may serve as a trigger factor for Takotsubo syndrome (TTS) in the same manner as severe physical stress factors
Summary
Most children infected by enterovirus 71 (EV71) develop either hand-foot-mouth disease (HFMD) or herpetic angina. AHF has been proposed as the major cause of early death in these patients [4,5,6,7,8,9,10,11,12], with EV-71 brainstem encephalitis-related hypercatecholaminemia believed as having a direct impact on the cardiotoxicity leading to AHF [7, 11, 13]. Jan and Fu et al found that patients with severe EV71 infection and AHF have clinical manifestations of sympathetic hyperactivity and significantly increased catecholamine concentrations. This result supports the hypothesis that hypercatecholaminemia is the cause of EV-71 related AHF [7, 11]. Acute heart failure (AHF) is the major cause of death in children with severe enterovirus 71 (EV71) infection. This study aimed to report our clinical experience with EV71-related AHF, as well as to discuss its pathogenesis and relationship to Takotsubo syndrome (TTS)
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