Pediatric Myocarditis Research Articles

Nursing care for children with fulminant myocarditis treated with extracorporeal membrane oxygenation.

To summarize the nursing experience of treating pediatric fulminant myocarditis with extracorporeal membrane oxygenation (ECMO). The intensive care unit of our hospital treated 6 children with fulminant myocarditis with ECMO from 2019 to 2022. The main nursing measures included establishing an ECMO rescue team, preparing before initiation of ECMO, management of arterial and venous catheters, enteral nutrition support, reducing the risk of infection aggravation, anticoagulation management, prevention of bleeding and thrombosis, management of ECMO pump failure, and post-ECMO care. One child's family abandoned treatment and left the hospital, while the other 5 children were transferred to the cardiovascular department after stable weaning from ECMO and continued treatment, with good condition, and eventually discharged. Pediatric fulminant myocarditis has a high mortality rate, but detailed evaluation and nursing care can improve the outcome of these patients.

Association Between Race/Ethnicity and Severity of Illness in Pediatric Cardiomyopathy and Myocarditis.

Previous reports demonstrate racial/ethnic differences in survival for children hospitalized with cardiomyopathy and myocarditis. The impact of illness severity, a potential mechanism for disparities, has not been explored. Using the Virtual Pediatric Systems (VPS, LLC), we identified patients ≤ 18 years old admitted to the intensive care unit (ICU) for cardiomyopathy/myocarditis. Multivariate regression models were used to evaluate the association between race/ethnicity and Pediatric Risk of Mortality (PRISM 3). Multivariate logistic and competing risk regression was used to examine the relationship between race/ethnicity and mortality, CPR, and ECMO. Black patients had higher PRISM 3 scores on first admission (𝛽 = 2.02, 95% CI: 0.15, 3.90). There was no difference in survival across race/ethnicity over multiple hospitalizations. Black patients were less likely to receive a heart transplant (SHR = 0.65, 95% CI: 0.45-0.92). Black and unreported race/ethnicity had higher odds of CPR on first admission (OR = 1.64, 95% CI: 1.01-2.45; OR = 2.12, 95% CI: 1.11-4.08, respectively). Black patients have higher severity of illness on first admission to the ICU, which may reflect differences in access to care. Black patients are less likely to receive a heart transplant. Additionally, Black patients and those with unreported race/ethnicity had higher odds of CPR, which was not mediated by severity of illness, suggesting variations in care may persist after admission.

Creatine phosphate improves myocardial function and myocardial enzyme profile in children with myocarditis

ABSTRACT Myocarditis in children is more common in clinical practice, which can cause different degrees of cardiac function damage. We investigated the effects of creatine phosphate in the treatment of myocarditis in children. Children in the control group were treated with sodium fructose diphosphate, and children in the observation group were treated with creatine phosphate on the basis of the control group. After treatment, the myocardial enzyme profile and cardiac function of children in the observation group were better than the control group. The total effective rate of treatment for children in the observation group was higher than that in the control group. In conclusion, creatine phosphate could significantly improve myocardial function, improve myocardial enzyme profile and reduce myocardial damage in children with pediatric myocarditis and had a high safety of use, which was worthy of clinical promotion.

Altered plasma exosome miRNAs and novel potential biomarkers in pediatric fulminant myocarditis

Previous studies have indicated that exosome-mediated intercellular microRNAs (miRNA) can influence fulminant myocarditis (FM) pathogenesis between immune and cardiac cells. This study explored plasma exosome miRNA profile in pediatric FM using a small RNA microarray. As per our analysis, we observed the differential expression of 266 miRNAs, including 197 upregulated and 69 downregulated candidate genes. Differentially expressed mRNAs in pediatric FM patients' peripheral blood mononuclear cells (PBMCs) were intersected with miRNA target genes predicting tools to screen for FM-specific target genes. The hub genes and their biological and mechanistic pathways related to inflammation and/or the immune system were identified. CeRNA networks of lncRNAs, circRNAs, miRNAs, and mRNAs between cardiomyocytes and PBMCs were finally established. Furthermore, we verified that hsa-miR-146a-5p, hsa-miR-23a-3p, and hsa-miR-27a-3p had higher expression levels in exosomes of pediatric FM patients by qRT-PCR, and hsa-miR-146a-5p shown high sensitivities and specificities for FM diagnosis. Overall, the results demonstrate that the exosome miRNAs play a regulatory role between immune and cardiac cells and provide research targets.

(673) Mechanical Circulatory Support, Heart Transplantation and Death in a Large-Scale Population of the Multicenter Registry for Suspected Pediatric Myocarditis - "MYKKE"

(673) Mechanical Circulatory Support, Heart Transplantation and Death in a Large-Scale Population of the Multicenter Registry for Suspected Pediatric Myocarditis - "MYKKE"

Factors affecting in-hospital mortality among pediatric patients with myocarditis treated with mechanical circulatory support

BackgroundMechanical circulatory support (MCS) is a common treatment modality for circulatory failure caused by pediatric myocarditis. Despite improvements in treatment strategy, the mortality rate of pediatric patients with myocarditis treated with MCS is still high. Identifying the factors associated with mortality among pediatric patients with myocarditis treated with MCS may help reduce the mortality rate. MethodsThis retrospective cohort study examined the data of patients aged <16 years who were admitted to a hospital between July 2010 and March 2018 for myocarditis; the data were collected from the Diagnosis Procedure Combination database, which is a national inpatient database in Japan. ResultsDuring the study period, 105 of the 598 patients with myocarditis were treated with MCS. We excluded seven patients who died within 24 h of admission, resulting in 98 eligible patients. The overall in-hospital mortality was 22 %. In-hospital mortality was higher among patients aged <2 years and those who received cardiopulmonary resuscitation (CPR). Multivariable logistic regression analysis showed significantly higher in-hospital mortality among patients aged <2 years old [odds ratio (OR), 6.57; 95 % confidence interval (CI), 1.89–22.87] and those who received CPR (OR, 4.70; 95 % CI, 1.51–14.63; p < 0.01). ConclusionThe in-hospital mortality of pediatric patients with myocarditis treated with MCS was high, particularly of children younger than 2 years and those who received CPR.

Corticosteroid in anti-inflammatory treatment of pediatric acute myocarditis: a systematic review and meta-analysis

BackgroundTo evaluate the efficacy of corticosteroids in anti-inflammatory treatment of pediatric acute myocarditis.MethodsWe searched PubMed, Embase and Cochrane library and included studies before October 2022 for clinical trials, observational studies and retrospective studies which reported on children with acute myocarditis treated with corticosteroid anti-inflammatory therapy. The quality of the clinical trials was assessed by Jadad score as an exclusion criterion.ResultsThis systematic review included 6 studies involving 604 pediatric patients with acute myocarditis. Corticosteroid therapy was not associated with reduced risk of mortality due to acute myocarditis (P = 0.53; RR = 0.87; 95% CI = 0.58 to 1.33) compared to anti-failure treatment. There was a significant improvement in pediatric patients’ left ventricular function measured by left ventricular ejection fraction in the group on corticosteroid anti-inflammatory treatment (P = 0.0009; MD = 11.93%; 95% CI = 4.87% to 18.99%). No conclusion can be drawn due to the high heterogeneity in meta-analyses of risk of getting to a clinical endpoint (death or heart transplantation) and changes in left ventricular end-diastolic diameter (LVEDD).ConclusionsCorticosteroid anti-inflammatory therapy in pediatric acute myocarditis patients showed no significant improvement in reducing the risk of mortality, but showed significant improvement in LVEF.

Pediatric Myocarditis.

Myocarditis is a condition caused by acute or chronic inflammation of the cardiac myocytes, resulting in associated myocardial edema and myocardial injury or necrosis. The exact incidence is unknown, but is likely underestimated, with more mild cases going unreported. Diagnosis and appropriate management are paramount in pediatric myocarditis, as it remains a recognized cause of sudden cardiac death in children and athletes. Myocarditis in children is most often caused by a viral or infectious etiology. In addition, there are now two highly recognized etiologies related toCoronavirus disease of 2019 (COVID-19) infection and the COVID-19 mRNA vaccine. The clinic presentation of children with myocarditis can range from asymptomatic to critically ill. Related to severe acute respiratory syndrome-Coronavirus 2 (SARs-CoV-2), children are at greater risk of developing myocarditis secondary to COVID-19 compared to the mRNA COVID-19 vaccine. Diagnosis of myocarditis typically includes laboratory testing, electrocardiography (ECG), chest X-ray, and additional non-invasive imaging studies with echocardiogram typically being the first-line imaging modality. While the reference standard for diagnosing myocarditis was previously endomyocardial biopsy, with the new revised Lake Louise Criteria, cardiac magnetic resonance (CMR) has emerged as an integral non-invasive imaging tool to assist in the diagnosis. CMR remains critical, as it allows for assessment of ventricular function and tissue characterization, with newer techniques, such as myocardial strain, to help guide management both acutely and long term.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

359 - An unusual presentation of pediatric acute idiopathic myocarditis in the era of the COVID-19 pandemic

359 - An unusual presentation of pediatric acute idiopathic myocarditis in the era of the COVID-19 pandemic

Lock the Doors: The Myocarditis Disaster and a call for the broad examination of the CDC and FDA

“Lock the doors.” uttered by LeRoy Cain, the flight director of STS-107, meant the complete loss of Space Shuttle Columbia. Locking the doors initiated the protocol to preserve data and logs for the impending investigation. Some hard lessons were learned from the Space Shuttle Challenger disaster 17 years earlier, one of which was that the National Aeronautics and Space Administration (NASA) should not be put in a position to investigate itself. The interagency Columbia Accident Investigation Board (CAIB) was formed to learn what we could from the fate of Columbia. Had NASA been the investigating agency, given the culture, it is possible the concluding cause would have been a random event such as bird strike after takeoff or micrometeoroid in orbit. “We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing.”[1] Those management practices point to lock-stepping, where dissenting opinions are discouraged or suppressed. NASA’s opinion was that foam is safe. When Bob Page, chair of NASA’s Intercenter Photo Working Group, saw foam strike the wing he raised an alarm that the heat shield may be compromised. He and two members of the Debris Assessment Team made a total of three requests to the Department of Defense (DoD) to obtain high-resolution images of Columbia’s left wing. A request that, by all accounts, the DoD was willing and able to fulfill. Those requests were subsequently canceled by the shuttle program managers. The CAIB report went on to say, “[t]he Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASAʼs Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry.” There are two vitally important lessons we have learned from NASA. The first is that a government agency should not be able to investigate itself. The second is that lock-stepping is lethal. The most advanced population health surveillance in the United States couldn’t find a single healthy child who died of COVID-19. Zero is a powerful number. Zero is also the number of vaccines that impart superior immunity over that of natural immunity. If we could choose one feature that the emergent 5th endemic cold virus could have, it would unequivocally be a minimal effect on children – safeguarding our future and allowing the progression of natural immunity. There is nothing mild about pediatric myocarditis. Even with the best medical management, 1/3rd of all patients never completely recovers, and will live with dilated cardiomyopathy. If untreated, 80% of children will develop chronic heart disease. These children are subject to a high risk of sudden death and may require an urgent heart transplant[2].

Unveiling the complexity of pediatric acute myocarditis: A multifaceted approach to understanding and managing a challenging syndrome

Unveiling the complexity of pediatric acute myocarditis: A multifaceted approach to understanding and managing a challenging syndrome

Extracorporeal Membrane Oxygenation Cannulation Timing in the Pediatric Myocarditis Population: An Exploratory Analysis From the Extracorporeal Life Support Organization Registry.

Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation. The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied. None. Population characteristics and survival were compared using t test, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007-2012 vs 2013-2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3 hr [interquartile range (IQR)], 1-14 hr vs 6 hr [IQR, 2-20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02-0.40; p = 0.002) for ITC time greater than or equal to 18 hours. The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.

Q wave in paediatric myocarditis: an underinvestigated, readily available prognostic factor

Background Myocarditis is an uncommon disease in children with potentially fatal consequences. An electrocardiogram (ECG) change seen in myocarditis is pathological Q wave. Pathological Q wave is linked to permanent damage and myocardial death in several cardiac diseases. We investigated the significance of pathological Q waves in children with acute myocarditis (AM). Methods This retrospective observational study analysed the data of 59 children with AM admitted to our hospital between January 2016 and July 2021. They were divided into Q wave and non-Q wave myocarditis groups. Patients’ laboratory data, echocardiography, treatment and hospital outcome were analysed. Results Patients were 64.4% male and had a median age of 6 years and 9 months. Pathological Q waves were found in 52.5% of the patients. Q wave myocarditis group had higher troponin I values (499 vs. 145 ng/L, p = 0.011) and longer hospital stays (13 vs. 9 days, p = 0.020) than the non-Q wave group. They also required higher doses of inotropic or vasoactive drugs. 61.3% of Q wave patients needed mechanical ventilation compared to 35.7% of non-Q wave patients (p = 0.069). All the patients who died or discharged with an LVEF < 30% belonged to the Q wave group. Conclusion Q wave in AM warrants close monitoring and intensive treatment as it accompanies more severe complications and poorer outcomes. This readily available ECG finding can be a clue to prognoses of AM patients. Further research with larger populations is needed to better understand Q wave prognostic accuracy and its potential role in guiding more expensive treatments.

Predicting factors and outcomes of acute myocarditis in children - a 5-year experience in a teaching hospital from the Eastern province of Saudi Arabia.

Myocarditis in children is not very common, but the state of the disease is similar to viral influenza, making it challenging for a clinician to make an early diagnosis and treatment plan. Elevated levels of inflammatory biomarkers like C-reactive protein, serum lactate, troponin, and abnormal ECG may be helpful for high-index suspicion of myocarditis. This study aimed to determine the predicting factors and outcomes of acute myocarditis in children admitted to a teaching hospital in the Eastern province of Saudi Arabia. Complete medical records of 80 pediatric patients with acute myocarditis over 5 years (from 2015 to 2019) were retrieved, including demographic characteristics, laboratory investigations including cardiac enzymes (serum lactate, CPR, and troponin), and ECG findings for the diagnosis of myocarditis based on tachycardia and bradycardia. There were 22 (27.5%) mortalities that took place during the hospital stay. Low WBC (mmol/dl) levels were associated with in-hospital mortality (p 0.001), whereas high serum lactate levels (>2 mmol) were not. Association of troponin level (0.15ng/mL) was not significantly associated with mortality (p=0.496). The area under the ROC=0.947 (95% C.I: 0.88-1.0) revealed highly significant predictive validity at the 2.3 best cutoff point, having 90.9% and 87.9% sensitivity and specificity, respectively. Clinical factors and elevated biomarkers were associated with poor prognosis and in-hospital mortality in pediatric myocarditis. Serum lactate and troponin levels demonstrated high predictive validity for early diagnosis.

P61 SARS-CoV-2 vaccine safety in adolescents with inflammatory rheumatic and musculoskeletal diseases and adults with juvenile idiopathic arthritis: data from the EULAR COVAX physician-reported registry

Introduction/BackgroundThere is a lack of data on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccination safety in children and young people (CYP) with rheumatic and musculoskeletal diseases (RMDs) as they were excluded from initial vaccine trials. Vaccination guidance is based on data from adults with or CYP without RMDs.Description/MethodOur objective was to describe the safety of SARS-COV-2 vaccination in adolescents with inflammatory RMDs and adults with JIA. We described patient characteristics, flares, and adverse events in adolescent cases under 18 with inflammatory RMDs and adult cases aged 18 or above with JIA submitted to the European Alliance of Associations for Rheumatology (EULAR) COVAX registry.Discussion/ResultsThirty-six adolescent cases were reported from 4 countries, mostly female (58%) with JIA (42%: 28% non-systemic JIA, 14% systemic JIA) and a median age of 15 [IQR: 14.5, 17]. Most were in remission (64%) or had minimal (22%) disease activity at the time of vaccination. Over half of the adolescent group (56%) reported early reactogenic-like AEs. One mild polyarthralgia flare and one serious AE of special interest (malaise) were reported. No CYP reported SARS-CoV-2 infection post-vaccination. No cases of paediatric inflammatory multi-system syndrome or myocarditis adverse events were reported.Seventy-four adult JIA cases were reported from 11 countries; 73% were female with a median age of 26 [IQR: 23, 31]. Eight-five percent had ns-JIA and 15% had s-JIA. Almost two thirds (62%) reported early reactogenic-like AEs and two flares were reported (mild polyarthralgia and moderate uveitis). No serious AEs of special interest were reported among adults with JIA. Three 20-30 year old females were diagnosed with SARS-CoV-2 post-vaccination; all fully recovered.Key learning points/ConclusionIn this observational registry dataset, SARS-CoV-2 vaccines appeared safe in adolescents with RMDs and adults with JIA, with a low frequency of disease flares, serious AEs, and SARS-CoV-2 re-infection seen in both populations.

Treating Pediatric Myocarditis with High Dose Steroids and Immunoglobulin.

There is considerable variability in practice among pediatric centers for treatment of myocarditis. We report outcomes using high dose steroids in conjunction with IVIG. This is a single center retrospective study of children < 21 years of age diagnosed with myocarditis and treated with high dose steroids and IVIG from January 2004-April 2021. Diagnostic criteria for myocarditis included positive endomyocardial biopsy, cardiac magnetic resonance (CMR) imaging meeting Lake Louise criteria, or strictly defined clinical diagnosis. Forty patients met inclusion criteria. Median age at diagnosis was 11.6 years (0.7–14.6). Diagnosis was made clinically in 70% of cases (N = 28), by CMR in 12.5% (N = 5) and by biopsy in 17.5% (N = 7). Median ejection fraction (EF) at diagnosis was 35% (IQR 24–48). Median duration of IV steroids was 7 days (IQR 4–12) followed by an oral taper. Median cumulative dose of IV immunoglobulin (IVIG) was 2 g/kg. There were no serious secondary bacterial infections after steroid initiation. Ten patients (25%) required mechanical circulatory support. Overall transplant free survival was 92.5% with median follow-up of 1 year (IQR 0–6 years). Six patients required re-admission for cardiovascular reasons. By 3 months from diagnosis, 70% of patients regained normal left ventricular function. High dose steroids in conjunction with IVIG to treat acute myocarditis can be safe without significant infections or long-term side effects. Our cohort had excellent recovery of ventricular function and survival without transplant. Prospective comparison of a combination of high dose steroids with IVIG versus other therapies is needed.

Pediatric Myocarditis and Pericarditis Complication after mRNA-based COVID-19 Vaccination

Oyster and co-authors (2022) have authored an article called Myocarditis cases reported after mRNA-based COVID-19 vaccination in the United States from December 2020 to August 2021, which studies and investigates the resulting number of cases of Myocarditis concerning the COVID-19 vaccination for pediatric patients older than 12 years of age but include individuals less than 30 years of age. From analyzing COVID 19 vaccination, there is more attribute towards the benefits associated with health matters as outlined by Bozkurt and co-authors (2021). However, from the research, the vaccination holds potential risks that would harm the population involved (Halushka &amp; Vander Heide, 2021). The article investigates the different reports of Myocarditis and pericarditis rates after mRNA-based vaccination in the United States and globally. With the detailed information, the article has reviewed additional existing knowledge to support the study’s objective. Public health Ontario 2022 also provides an overview of the event of Myocarditis and Pericarditis following mRNA COVID 19 vaccines. Data from other countries also reported Cases of Myocarditis/Pericarditis following immunization with mRNA vaccine in Ontario, Canada, and internationally. Reported cases have occurred more frequently in males under 30 years, following the second dose, usually within one week of vaccination, and have mild with quick recovery. Although they also mention that the benefit of vaccination continues to outweigh the risk of COVID-19 illness, the authority still recommends vaccination for all eligible individuals, including children and youth. Also, per the American college of cardiology, vaccine-associated Myocarditis is a rare but possible side effect after m-RNA based COVID-19 vaccine. The clinical course of this Myocarditis is generally mild, with most symptoms resolving quickly.

Pathogenic Variants in Cardiomyopathy Disorder Genes Underlie Pediatric Myocarditis-Further Impact of Heterozygous Immune Disorder Gene Variants?

Myocarditis is an inflammatory disease of the heart. Pediatric myocarditis with the dilated cardiomyopathy (DCM) phenotype may be caused by likely pathogenic or pathogenic genetic variants [(L)P] in cardiomyopathy (CMP) genes. Systematic analysis of immune disorder gene defects has not been performed so far. We analyzed 12 patients with biopsy-proven myocarditis and the DCM phenotype together with their parents using whole-exome sequencing (WES). The WES data were filtered for rare pathogenic variants in CMP (n = 89) and immune disorder genes (n = 631). Twelve children with a median age of 2.9 (1.0–6.8) years had a mean left ventricular ejection fraction of 28% (22–32%) and myocarditis was confirmed by endomyocardial biopsy. Patients with primary immunodeficiency were excluded from the study. Four patients underwent implantation of a ventricular assist device and subsequent heart transplantation. Genetic analysis of the 12 families revealed an (L)P variant in the CMP gene in 8/12 index patients explaining DCM. Screening of recessive immune disorder genes identified a heterozygous (L)P variant in 3/12 index patients. This study supports the genetic impact of CMP genes for pediatric myocarditis with the DCM phenotype. Piloting the idea that additional immune-related genetic defects promote myocarditis suggests that the presence of heterozygous variants in these genes needs further investigation. Altered cilium function might play an additional role in inducing inflammation in the context of CMP.

Clinical Presentation, Complications and Early Predictors for Poor Outcomes in Pediatric Myocarditis in a Tertiary Care Hospital

Objective: To evaluate common clinical presentation, complications and poor prognostic outcomes in children with acute myocarditis.&#x0D; Study Design: Prospective longitudinal study.&#x0D; Place and Duration of Study: Pediatric Cardiology Department, National Institute of Cardiovascular Disease Karachi Pakistan, from Feb to Aug 2020.&#x0D; Methodology: The children aged one month to 16 years were included in the study. Clinical, demographic features, Electrocardiogram, Echocardiography, management, complications, and immediate outcomes were recorded.&#x0D; Results: The total number of patients enrolled was 161. The median age was 5.01 ± 3.38 years for 66.4% of males and 33.5% females, mean Duration of symptoms was 8.35 ± 3.49 days. Upper respiratory tract infection was present in 84 (52.2%) and diarrhea in 8 (5%) in the preceding illness. Symptoms and signs include loss of appetite in 153 (96.27%), irritability in 148 (91.9%), vomiting in 132 (82%) and abdominal pain in 112 (69.6%), tachycardia in 148 (91.9%) and pallor in 143 (88.8%). Low voltage ECG was present in 125 (77.6%), arrhythmias in 12 (7.45%) and heart block in 6 (3.7%). Left ventricle end-diastolic dimensions (LVIDD)&gt;4SD were present in 30.2% and LV end-systolic dimensions (LVIDS)&gt;4SD in 19.5%, Left ventricular ejection fraction (LVEF)mean was 21.13 ± 5.07 vs 23.45 ± 3.31 at discharge. 9.21% of patients expired, out of which 78.5% had Left bundle branch block (LBBB), mean LVEF was 16.24 ± 3.16, LVID d&gt;4SD in 78%, and LVIDs&gt;4SD in 30%.&#x0D; Conclusion: The most frequent presentations were loss of appetite, difficulty breathing, irritability and abdominal pain. Tachycardia and pallor were......