Diagnosis Of Fulminant Myocarditis Research Articles

Characteristics of Electrocardiogram Findings in Fulminant Myocarditis.

Fulminant myocarditis (FM) is an acute and severe form of myocarditis with rapid progression and poor clinical outcomes in the absence of acute or chronic coronary artery disease. Electrocardiogram (ECG) abnormalities can provide preliminary clues for diagnosis; however, there is a lack of systemic descriptions on ECG changes in FM populations. Thus, a retrospective analysis of 150 consecutive FM patients and 300 healthy controls was performed to determine the characteristic ECG findings in FM. All patients included had markedly abnormal ECG findings. Specifically, 83 (55.33%) patients had significantly lower voltage with remarkably decreased QRS amplitudes in all leads compared with healthy controls (p < 0.01), and 77 (51.33%) patients had a variety of arrhythmias with lethality ventricular tachycardia/ventricular fibrillation in 21 (14.00%) patients and third-degree atrioventricular block in 21 (14.00%) patients, whereas sinus tachycardia was only found in 43 (28.67%) patients with the median heart rate (HR; 88.00 bpm, IQR: 76.00-113.50) higher than that of controls (73.00 bpm, IQR: 68.00-80.00) (p = 0.000). Conduction and repolarization abnormalities were common in patients. A longer QTc interval (452.00 ms, IQR: 419.00-489.50) and QRS duration (94.00 ms, IQR: 84.00-119.00) were observed in patients compared to controls (QTc interval = 399.00 ms, IQR: 386.00-414.00; QRS duration = 90.00 ms, IQR: 86.00-98.00) (p < 0.05). Additionally, HR > 86.50 bpm, QTc > 431.50 ms, and RV5 + SV1 < 1.715 mV can be used to predict FM. Thus, marked and severe ECG abnormalities provide preliminary clues for the diagnosis of FM.

Acute myocarditis during adjuvant therapies for breast cancer: a case report

BackgroundWith the improvement of optimal perioperative drug therapy for breast cancer patients, physicians now have to treat the adverse effects and comorbidities associated with long-term treatments. We report a case who suffered cardiac arrest due to acute myocarditis developed after initiation of adjuvant treatment.Case presentationAfter completing preoperative chemotherapy and undergoing curative surgery for right breast cancer, a 46-year-old female patient started adjuvant tamoxifen and resumed trastuzumab. Two months later, she complained fever and dyspnea. Blood tests showed a marked increase in hepatic enzymes, and the patient was rushed to our emergency room on suspicion of drug-induced liver injury. In the emergency room, the patient went into cardiac arrest shortly after tachycardia with ST-segment elevation appeared on the monitored electrocardiogram. Resuscitation was started immediately and tracheal intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation were started. Coronary angiography results were negative for ischemic heart disease. A diagnosis of fulminant myocarditis was made and steroid pulse therapy and immunoglobulin therapy were started. After the start of treatment, the symptoms of heart failure improved steadily and the patient was discharged on the 28th day. Histological findings of the myocardial biopsy revealed degeneration and necrosis of myocardial cells with marked lymphocytic infiltration, consistent with the histology of lymphocytic myocarditis. Serum cytomegalovirus, coxsackie B virus and adenovirus antibodies were all elevated and these findings were consistent with acute viral myocarditis.ConclusionsWe report a case with strong indications for therapy-induced liver damage, who was ultimately diagnosed with acute viral myocarditis and successfully treated with multidisciplinary therapy. We believe that our findings would be useful for other clinicians in managing similar patients.

Acute myocardial calcification in a patient with fulminant myocarditis.

Relationship with Industry: None A 38-year-old man was admitted with a 3-week history of rapid clinical deterioration. The patient presented with multisystem inflammatory syndrome associated with multi-organ failure (white blood and polynuclear cells counts at respectively 54.40 and 51.60 *109/L; C-reactive protein, Ferritin and Fibrinogen levels at respectively, 214 mg/L, 1624 μg/L, and 8.31 g/L; and creatinine and bilirubin levels at respectively 397 μmol/L (4,49 mg/dL) and 57 μMol/L (3,33 mg/dL)). Large screening and multiple testing for bacterial and viral infections remained negative in a patient with Covid-19 infection 3-months earlier without vaccination. The patient was transferred to the Intensive Care Unit necessitating mechanical ventilation, hemodialysis, and inotropic support. Rapidly, diffuse ST elevation on electrocardiogram and increased levels of high-sensitivity cardiac I troponin (hs-cTnI = 135000 ng/L) and natriuretic peptide (NT-ProBNP = 72114 ng/L) were found. Coronary angiogram showed no significant coronary disease and transthoracic echocardiography (TTE) showed reduced left ventricular ejection fraction (LVEF = 40%). Cardiac magnetic resonance imaging confirmed diffuse and extensive gadolinium uptake. Despite negative cardiac biopsies, the diagnosis of fulminant myocarditis was made and the patient underwent corticosteroids bolus and intravenous immunoglobulin therapies. Clinical evolution was deemed favourable with a progressive decrease in systemic inflammatory process associated with a decrease in cardiac biomarkers levels. However, 2 weeks later, chest X-ray (Panel A) and TTE (Panel B) showed acute and impressive left ventricular calcified remodelling process with diffuse epicardial calcification and septal patchy fibrosis (whites triangles). The positron emission tomography (PET-CT) confirmed the diffuse FDG uptakes suggesting persistent local inflammatory process (Panel C) associated with large epicardial calcified remodelling (Panel D). The patient was discharged 1 month after the index admission with optimized heart-failure therapy and planned follow-up at the Heart Failure Clinic.

Plasma Siglec-5 and CD163 as Novel Biomarkers for Fulminant Myocarditis.

Fulminant myocarditis (FM) is the severest type of myocarditis and requires timely diagnosis and treatment. However, effective biomarkers for early diagnosis of FM are limited. First, 12 common inflammatory cytokines levels in the plasma of patients with FM were measured using human cytokine 12-Plex assay. Then, enzyme-linked immunosorbent assay (ELISA) was used to detect the plasma levels of another eight cytokines that we previously reported on. Moreover, a Spearman correlation test was employed to investigate the correlations between the plasma cytokine levels and the clinical parameters of patients with FM. Finally, receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic performance of plasma cytokine levels for the detection of FM. Five of the twelve common inflammation cytokines were significantly altered in patients with FM, but none of them was correlated with the severity of FM. Six of the eight significantly changed cytokines that we previously reported on were validated by ELISA. Among these, sST2, Siglec-5, and CD163 were negatively correlated with ejection fraction values. Furthermore, plasma Siglec-5 and CD163 levels were found to be associated with the severity of FM. Finally, both plasma Siglec-5 and CD163 showed outstanding diagnostic performance for FM. The current study identified plasma Siglec-5 and CD163 as valuable novel biomarkers for the early diagnosis of FM.

Soluble ST2 Is a Sensitive and Specific Biomarker for Fulminant Myocarditis.

BackgroundThe aim of the study was to identify biomarkers that can facilitate early diagnosis and treatment of fulminant myocarditis (FM) in order to reduce mortality.Methods and ResultsFirst, the expression profiles of circulating cytokines were determined in the plasma samples from 4 patients with FM and 4 controls using human cytokine arrays. The results showed that 39 cytokines from patients with FM were changed at admission. Among them, 8 cytokines returned to normal levels at discharge, including soluble ST2 (sST2), which showed the most marked dynamic changes from disease onset to resolution. Then, in a cohort of 76 patients with FM, 57 patients with acute hemodynamic dysfunction attributable to other causes, and 56 patients with non‐FM, receiver operating characteristic curve analyses suggested that plasma sST2 level was able to differentiate FM from non‐FM or other FM‐unrelated acute heart failure more robustly N‐terminal pro‐B‐type natriuretic peptide or cardiac troponin I. Moreover, longitudinal analysis of plasma sST2 was performed in 10 patients with FM during hospitalization and 16 patients with FM during follow‐up. Finally, the diagnostic value was validated in an additional 26 patients with acute onset of unstable hemodynamics. The cutoff value of plasma sST2 for optimal diagnosis of FM was established at 58.39 ng/mL, where a sensitivity of 85.7% and specificity of 94.7% were achieved.ConclusionsElevated sST2 level was associated with mechanical stress or inflammation. Especially, sST2 might be used as a potential biomarker for the rapid diagnosis of FM, which was characterized by strong mechanical stretch stimulation and severe inflammatory response.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03268642.

Expression and Significance of Circulating microRNA-29b in Adult Fulminant Myocarditis

Objective To explore the expression profiles of circulating microRNA(miRNA)and potential markers for the diagnosis of adult fulminant myocarditis(FM). Methods The expression profiles of circulating miRNA were determined by microarray analysis and verified by real-time quantitative PCR.The key role of circulating miRNA in FM was determined via KEGG pathway enrichment.The correlations between miRNA and cardiac function parameters in patients with FM were analyzed.The receiver operating characteristic(ROC)curve was established to evaluate the sensitivity and specificity of circulating miRNA in the diagnosis of FM. Results Compared with healthy controls,the FM patients had up-regulated expression levels of miR-29b(t=18.925,P<0.001)and miR-125b(t=5.981,P=0.029)in the plasma.After treatment,the expression levels of miR-29b(t=12.943,P<0.001)and miR-125b(t=14.016,P<0.001)were significantly down-regulated.KEGG pathway enrichment showed that the targets of miR-29b were involved in inflammatory response and apoptosis pathways.The results of cell proliferation and apoptosis assay demonstrated the transfection of miR-29b mimic had a more significant inducing effect on cardiomyocyte apoptosis than that of miR-125b mimic(χ 2=6.168,P=0.047),whereas there was no significant difference in the inhibition of cell proliferation between the two groups(χ2=1.452,P=0.417).The expression levels of miR-29b and miR-125b were negatively correlated with left ventricular ejection fraction(r=-0.67,P=0.071;r=-0.49,P=0.003).They were positively correlated with cardiac troponin I level(r=0.61,P=0.019;r=0.52,P=0.016),interferon β level(r=0.42,P=0.014;r=0.36,P=0.021),and myocardial edema area(r=0.86,P=0.005;r=0.73,P=0.013).The ROC curve analysis demonstrated that miR-29b had higher sensitivity for the diagnosis of FM(93.6% vs.89.2%;t=0.896,P=0.795)and specificity(72.4% vs.59.6%;t=9.478,P=0.002)than miR-125b. Conclusion The circulating miR-29b may be a potential biomarker for the diagnosis of FM.

PARVOVIRUS B19 INDUCED MYOCARDITIS, SIMULATING ACUTE MYOCARDIAL INFARCTION

Myocarditis is an inflammation of the myocardium associated with mechanical or electrical dysfunctions that usually lead to inappropriate ventricular dilatation or hypertrophy. A number of inciting factors are known to cause myocarditis- genetic defects, viruses, bacteria, parasites, granulomatous inflammations, collagen vascular disorders, chemotherapeutic agents- to name a few. Among the viruses, Adenovirus, Coxsackie virus, Human Herpes virus six and Parvovirus B19 are the encountered pathogens. We hereby present a case of a 14 years old boy who presented with typical cardiac chest pain associated with electrocardiographic changes of ST segment elevation MI in theinferior leads. Cardiac biomarkers were elevated, adding to the diagnostic confusion of MI. On subjecting the patient to a coronary angiography, his arteries were found to be patent, directing us towards the diagnosis of myocarditis. After getting a cardiac MRI and serum tests, the diagnosis of fulminant myocarditis induced by Parvovirus B19 was made. Fortunately, the patient survived on inotropes and other supportive therapy which helped him overcome the cardiac failure.

Myocardial strain features by 2D-STE during the course of fulminant myocarditis: Correlation with characteristics by CMR and clinical implications.

Myocardial strain analysis by 2D speckle tracking echocardiography could determine the left ventricular function. Our purpose is to investigate the global longitudinal strain (GLS) changes during the course of fulminant myocarditis (FM) and evaluate their correlation with cardiac magnetic resonance (CMR).Patients with clinical diagnosis of FM from June 30, 2017 to June 30, 2019 were screened prospectively. 18 survived patients (mean age 34 ± 18 years) who had two scans of transthoracic echocardiography and underwent CMR were included.All patients had severely impaired left ventricular ejection fraction and GLS value at admission that improved significantly before discharge. The patients in the healed stage revealed elevated global native T1 and T2 relaxation time and extracellular volume fraction as well, which were 1408.3 ± 88.3ms, 46.56 ± 5.23ms, and 0.35 ± 0.09, respectively. GLS from the second transthoracic echocardiography in the healed stage correlated significantly with global native T1 relaxation time (r =-0.574, P = .013) and with extracellular volume fraction (r = -0.582, P = .011), but not global native T2 relaxation time (r = -0.31, P = .211) and not with late gadolinium enhancement mass (r = 0.084, P = .743). In comparison, GLS at admission were not correlated with CMR parameters of fibrosis and oedema in the healed stage.GLS by 2D-STE may emerge as a new tool to monitor inflammatory myocardial injuries during the course of FM. FM in the acute healed stage has the presence of both chronic fibrosis and oedema which are correlated with GLS, but GLS at admission can’t predict the early recovery of myocardial inflammation.

Expert consensus statement on the diagnosis and treatment of fulminant myocarditis in the context of the COVID-19 pandemic

The article contains Russian expert consensus statement on the diagnosis and treatment of fulminant myocarditis (FM), prepared by the National Society for the Study of Lipidology and Associated Metabolic Diseases, the Society of Internal, Sports and Preventive Medicine based on the clinical guidelines of the Russian Society of Cardiology, results of China Clinical Study (NCT03268642), Expert Guidelines of Russian Clinical and Research Center of Gerontology, Chinese Society of Geriatrics, Cardiology Branch of Beijing Medical Association. Pathogenesis, diagnosis and treatment of myocardial injury and FM in patients infected with SARS-CoV-2 in the context of the COVID-19 pandemic are discussed. Clinical features and diagnostic criteria of FM, as well as and comprehensive therapy for myocardial injury and FM are presented. The proposed protocol for the management of patients with myocardial injury in patients infected with SARS-CoV-2 was adapted with the clinical experience of Chinese experts. The protocol for anticoagulant and antiplatelet therapy was proposed by the Moscow State University Medical Center.

Serum exosome microRNA panel as a noninvasive biomarker for molecular diagnosis of fulminant myocarditis

Exosome-derived microRNAs (miRNAs) are potential diagnostic biomarkers. However, little is known about their effectiveness as diagnostic biomarkers of fulminant myocarditis (FM). This study aimed to explore serum exosomal miRNAs as potential biomarkers for FM diagnosis. Peripheral blood samples were collected from 99 patients with FM, 32 patients with nonfulminant myocarditis (NFM), and 105 healthy controls (HCs). The miRNA expression profiles of serum exosomes were determined using next-generation sequencing, and differentially expressed miRNAs were further analyzed by quantitative reverse transcriptase polymerase chain reaction. A logistic regression model was constructed using a training cohort (n = 120) and then validated using an independent cohort (n = 106). The area under the receiver operating characteristic curve was used to evaluate diagnostic accuracy. In FM patients, hsa-miR-30a, hsa-miR-192, hsa-miR-146a, hsa-miR-155, and hsa-miR-320a were validated as significantly and differentially expressed candidates that could serve as potential markers for diagnosing FM. In addition, the miRNA panel (hsa-miR-155 and hsa-miR-320a) from the multivariate logistic regression model demonstrated high accuracy in the diagnosis of FM and was able to distinguish FM from HCs and NFM. Moreover, the diagnostic value of the miRNA panel was greater than that of CRP and cTn alone or together. The miRNA panel provided the excellent diagnostic capability for FM.

Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline.

The features of myocardial strains from speckle-tracking echocardiography (STE) have not been well defined in fulminant myocarditis (FM) patients. In this study, changes in the left ventricular ejection fraction (LVEF) and global and layer-specific myocardial strains over time were monitored. We aimed to determine the echocardiographic patterns of FM and ascertain their significance in FM treatment. Twenty patients who were clinically diagnosed with FM and received mechanical life support were prospectively enrolled. Conventional echocardiographic measurements were obtained, and serial strain echocardiography was performed from admission to hospital discharge until LVEF recovery (> 50%). Global/regional peak systolic longitudinal strains (GLS/RLS) and layer-specific longitudinal strains were quantified, and their changes with time were monitored in 14 FM patients. All patients had severely impaired cardiac function. Steep improvement in LVEF and GLS were observed within 6 days. Layer-specific strain analysis showed that reduction at admission or recovery at discharge in the endocardium and epicardium strains were equal. In conclusion, FM patients who received mechanical circulatory supports exhibited steep improvement in ventricular function within 6 days. The patchy and diffused distribution pattern of reduced RLS and equally and severely impaired strain in the endocardium and epicardium are valuable features in the diagnosis of FM.

Myocarditis Associated with Mesalazine: A Case Report

Acute myocarditis is a life-threatening inflammatory disease of the heart muscle. It usually occurs after a viral infection and it is often asymptomatic. Mesalazine is commonly used for the treatment of inflammatory bowel disease. Mesalazine rarely causes acute myocarditis, but the exact mechanism is unclear. A 32-year-old female patient using mesalazine with a diagnosis inflammatory bowel disease was admitted to the emergency department with shortness of breath. The patient showed signs of acute decompansated heart failure. Bedside echocardiography examination showed a reduced left ventricular systolic function. The patient was followed with a diagnosis of fulminant myocarditis and mechanical ventilation and inotropic support was started. The patient has dramatically improved after stopping treatment of mesalazine. Myocarditis due to any drug use should be taken into consideration in patients receiving mesalazine therapy. Key Words: Mesalazine; Myocarditis; Crohn’s Disease.

Acute Mechanical Circulatory Support for Fulminant Myocarditis Complicated by Cardiogenic Shock

In fulminant myocarditis complicated by cardiogenic shock, early mechanical circulatory support (MCS) may prevent cardiomyopathy and death. We sought to examine the outcomes of patients with fulminant myocarditis supported with MCS. A retrospective review of patients with acute cardiogenic shock treated with MCS from 2007 to 2013 was conducted, and patients with a diagnosis of fulminant myocarditis were included in this series. At our center, 260 patients received MCS for acute cardiogenic shock, and 11 were implanted for fulminant myocarditis. Eight received the Centrimag biventricular assist device (BIVAD), and three received veno-arterial extracorporeal membrane oxygenator (VA ECMO), though 1 VA ECMO-supported patient was transitioned to BIVAD due to refractory shock. The mean acute support time was 14.7 ± 4.4 days. Two patients required long-term left ventricular assist devices and were further supported for 55 and 112 days. Eight patients recovered with a mean ejection fraction of 54 ± 7 %, and one was successfully transplanted. Eight patients survived to discharge (73 %) with mean follow-up: 292.6 ± 306.8 days. All three deaths were due to neurologic complications. MCS should be considered in patients with fulminant myocarditis complicated by shock. With aggressive medical therapy, early utilization of MCS carries promising outcomes.

Predictive Score for Survival After Percutaneous Cardiopulmonary Support in Cardiovascular Disease Patients

The predictive factors for survival after percutaneous cardiopulmonary support (PCPS) are unknown. Data for 105 patients with cardiovascular disease requiring PCPS were analyzed. The patients were divided into a survivor (n=21) or a non-survivor group (n=84). The age was significantly lower, and there were more patients with fulminant myocarditis and PCPS attempted before cardiac arrest (CA) in the survivor group. Additionally, there were fewer cases of out-of-hospital CA, and the mean time from CA to PCPS was shorter in the survivor group. On multivariate logistic regression it was found that the age and the time from CA to PCPS were independently associated with survival. A predictive scoring system was constructed that included the following: (1) age <50 years; (2) diagnosis of fulminant myocarditis; (3) no out-of-hospital CA; (4) PCPS attempted before CA; and (5) time from CA to PCPS <45 min. The predictive score was significantly higher in the survivor than in the non-survivor group (2.33 ± 1.32 vs. 1.06 ± 1.02). The sensitivity and specificity for survival were 85.7% and 66.7% when the score was ≥ 2. Kaplan-Meier survival analysis showed that any-cause death was significantly higher in patients with PCPS survival score ≤ 1 than in those with a score ≥ 2. PCPS survival score is suitable for clinically predicting survival in patients with cardiovascular disease undergoing PCPS.

Successful treatment of fulminant myocarditis in a 7 year old with a left ventricular assist device

We present a case of a 7-year-old, 20-kg male child, admitted in our Center with a diagnosis of fulminant myocarditis with a large pericardial effusion and severe hemodynamic instability. Due to failure of medical therapy, a left ventricular assistant device (LVAD) was implanted. After 4 days, the patient was successfully weaned from mechanical support. Myocardial biopsy showed evidence of acute viral myocarditis. Our experience suggests that the left ventricular assist device therapy might offer circulatory support in pediatric cases of fulminant myocarditis. Keywords: fulminant myocarditis; mechanical circulatory support; heart failure (Published: 25 March 2011) Citation: Mechanical Circulatory Support 2011, 2 : 5762 - DOI: 10.3402/mcs.v2i0.5762

Plötzlicher Herztod 43 Monate nach fulminanter Myokarditis und zweizeitiger Myositis bei Salmonella-enteritidis-Infektion

A previously healthy 29-year-old male was hospitalized due to acute myalgia and high temperature following an uncomplicated gastroenteritis. Within 24 hours, he developed life-threatening hemodynamic shock with the need for inotropic support and sustained ventricular tachycardia. Echocardiography and electrocardiogram as well as lab tests were consistent with the diagnosis of fulminant myocarditis and acute myositis. Serological and bacteriological analysis yielded an acute infection with salmonella D. The patient's condition stabilized under conservative supportive care within a few days. Apart from a histologically confirmed recurrent myositis four weeks later, no further complications occurred and the patient was clinically and echocardiographically considered to be in complete functional remission. Three and a half years later, however, the patient unexpectedly and suddenly died. Although fulminant myocarditis is a life-threatening condition in its initial phase, the prognosis after recovery is considered to be good. However, this case study suggests that sudden cardiac death as a late complication of fulminant myocarditis may occur.

Myocardite aiguë fulminante mimant un infarctus du myocarde chez une enfant de 6 ans

Acute myocarditis is a rare inflammatory cardiac disease in children with potentially fatal issue. Clinical findings are very variable from nausea and vomiting to acute cardiovascular collapse. The cardiac function can be reversible with circulatory support. We report the case of a 6-year-old girl with ECG changes like myocardial infarction and diagnosis of fulminant myocarditis. She developped rapidly a cardiogenic shock and died before treatment with mechanical circulatory support.