Cardiac Troponin T: A Marker in the Diagnosis of Acute Myocarditis in Children

This study was conducted to assess the use of serum cardiac troponin T (cTnT) level as a noninvasive indicator to diagnose acute myocarditis in children. Noninvasive conventional methods often fail to diagnose myocarditis, A median cTnT level of 0.088 ng/ml (0.04–3.11) was reported in pediatric patients with acute myocarditis in our previous study. Hence, we attempted to determine the cutfoff level of cTnT to diagnose acute myocarditis in children. Pediatric patients with clinically suspected myocarditis or dilated cardiomyopathy (DCM) and a control group were recruited. History, physical examination, elctrocardiogram, chest roentgenogram, echocardiogram, cTnT level, and/or endomyocardial biopsy and clinical course were studied. The gold standard to diagnose acute myocarditis was endomyocardial biopsy proved according to the Dallas criteria and/or recovery from cardiovascular problems within 6 months of follow-up. Forty-three patients were admitted due to cardiovascular problems from primary myocardial dysfunction. Twenty-four patients were diagnosed as acute myocarditis (group 1), 19 were idiopathic chronic DCM (group 2), and 21 patients had moderate to large ventricular septal defect and congestive heart failure (group 3). Median cTnT level was statistically higher in (group 1) compared to groups 2 and 3. Ejection fraction (EF) and left ventricular end diastolic dimension (LVEDd) z score of acute myocarditis were 38.5% (range, 21–67) and 1.3 (range, –0.8–3.0), respectively, which were significantly better than DCM [28.0% (range, 17–45) and 6.0 (range, 2.0–10.0)]. The cutoff point of cTnT level to diagnose acute myocarditis was 0.052 ng/ml (sensitivity, 71%; specificity, 86%). cTnT level, EF, and LVEDd z score did not predict short-term outcomes of patients. In acute myocarditis, cTnT level and EF were significantly higher and LVEDd z score was significantly lower than in DCM. However, the three parameters had no significant effect on outcomes of the patients. Our data show that cardiac a cTnT level of 0.052 ng/ml is an appropriate cutoff point for the diagnosis of acute myocarditis.     

Myocarditis and pericarditis in children

Myocarditis and pericarditis are rare but important causes of pediatric chest pain. The diagnostic criteria, clinical course, causes, and treatment of myocarditis is reviewed. There is particular attention to the relationship of myocarditis with dilated cardiomyopathy. Supportive therapy remains the standard of care for pump dysfunction. The identification and treatment of pericarditis with associated large pericardial effusion can be lifesaving. This article reviews the important clinical features that might lead the clinician to diagnose either myocarditis or pericarditis and thus separate the few patients with either of these conditions from the legions of children with noncardiac chest pain.     

Muronomab-CD3 for Pediatric Acute Myocarditis

The treatment of pediatric acute myocarditis that is hemodynamically significant often includes immune modulation with intravenous immunoglobulin (IVIG) and steroids, and supportive measures. In this population, published outcomes include recovery of ventricular function from 6 months to years, transplantation, or death. We studied the effect of the immunosuppressive agent muronomab-CD3 (OKT3) on recovery of heart failure in the treatment of pediatric myocarditis. A retrospective chart review was performed identifying 15 pediatric patients diagnosed with acute myocarditis and depressed left ventricular ejection fraction (LVEF) or arrhythmias to which OKT3 was added to the immunosuppressive regimen. All patients were treated with supportive care, intravenous immunoglobulin, and steroids. LVEF by echocardiogram was plotted for each patient versus time. Outcomes included recovery of left ventricular function (as defined by an LVEF ≥ 45%), death, or listing for transplant. The diagnosis of acute myocarditis was made by a positive endomyocardial biopsy in 8 patients. Nine patients required extracorporeal membrane oxygenation (ECMO) or LV assist device. After treatment with OKT3, 9 patients made a significant recovery of LVEF within 17 days, and 1 recovered by 60 days. Six of the patients requiring mechanical assistance recovered within this time period. There were 4 deaths––3 due to ECMO complications and 1 due to underlying gastrointestinal illness. One patient diagnosed with chronic myocarditis on biopsy underwent transplantation. No significant side effects attributable to OKT3 occurred. By decreasing the autoimmune inflammatory response, OKT3 may hasten recovery of ventricular function and be a useful adjunct therapy for hemodynamically significant acute pediatric myocarditis.     

Fatal Cephalosporin-Induced Acute Hypersensitivity Myocarditis

A frequently fatal, although rare, side effect of cephalosporin antibiotics is noninfectious myocarditis. We report two cases of hypersensitivity myocarditis secondary to administration of cephalosporin antibiotics. In both cases, acute hypersensitivity myocarditis was not suspected clinically, and the diagnosis was made postmortem. Histology revealed intense eosinophilic infiltration of the endomyocardium with eosinophil degranulation and myocyte damage, Clinically, death in both cases was due to cardiac failure. When suspected early, appropriate management may be lifesaving.     

Successful Heart Transplantation Following Neonatal Necrotic Enterovirus Myocarditis

Enterovirus myocarditis is a potentially devastating diagnosis in the neonatal setting, with an associated high mortality and risk for chronically impaired cardiac function. Transplantation may be a possible therapeutic option, but, due to the comparative scarcity of the presentation, the limited donor pool, and fears of viral persistence and recurrence of myocarditis (especially in the immunocompromised, post-transplant setting), there are no reported cases in the literature. This case report illustrates an encouraging one-year outcome following heart transplantation for necrotic enterovirus myocarditis in a neonate.     

Eosinophilic Myocarditis Presenting with Pediatric Myocardial Infarction

Determination of the etiology of myocardial infarction (MI) in children can present a challenge to the practitioner since cases of pediatric MI are rare and the causes can be diverse. We report an unusual case of pediatric eosinophilic myocarditis that presented with MI.     

Junctional Ectopic Tachycardia Following Complete Heart Block Associated with Viral Myocarditis

We describe the case of an infant progressing from sinus rhythm to complete heart block, junctional ectopic tachycardia, and back to sinus rhythm as the only manifestation of viral myocarditis.     

Myocarditis in infants and children: A review for the paediatrician

Clinical myocarditis is uncommon in infants and children. The most common pathogen is Coxsackievirus B. The offending agent triggers an immune response, which results in myocardial edema with subsequent impairment of systolic and diastolic function. Newborns and infants are more severely affected because the immature myocardium has limited ways of adapting to an acute insult. Children typically present with sinus tachycardia and gallop on auscultation, cardiomegaly on chest x-ray and small voltages on electrocardiogram. The echocardiogram shows reduced ventricular function. Viral studies can isolate the pathogen. Myocardial biopsy is useful diagnostically, but carries a significant risk for the sick infant. The first line of treatment includes measures such as rest, oxygen and diuretics. Inotropic agents are useful in moderate to severe heart failure. The role of immunosuppressive therapy is not yet clearly established in the paediatric age group. Prognosis is guarded in newborns but more favourable in older children.     

病毒性心肌炎患儿免疫状况的研究

目的：探讨病毒性心肌炎 (VMC)患儿在细胞免疫、体液免疫和自身免疫方面的改变,从而指导免疫治疗。方法：用流式细胞技术分别测定 30例急性期、2 2例迁延期VMC患儿及30例对照的血清CD2 3,CD3/HLA DR,用比浊法测IgG,IgA和IgM。 结果：VMC患儿急性期、迁延期的CD2 3,IgG ,IgA ,IgM及CD3+ /HLA -DR+,CD3-/HLA -DR+ 细胞比例均高于正常对照组 (P均 <0 .0 1)。VMC患儿CD2 3和IgG ,IgA ,IgM呈正相关 (r分别=0.30,0.17,0.40,P<0.0 5),而急性期、迁延期VMC患儿的CD3+ /HLA DR-细胞表达率与正常对照组相比均无明显差异 (P均 >0 .0 5 )。迁延期患儿的各项指标和急性期相比无明显差异(P均>0.05)。结论：病毒性心肌炎患儿急性期、迁延期的细胞免疫、体液免疫均处于增强状态,提示细胞免疫、体液免疫可能参与了VMC患儿的心肌损伤。     

The Clinical Course of Acquired Complete Heart Block in Children with Acute Myocarditis

A case of biopsy-proven myocarditis in a 7-year-old complicated by advanced atrioventricular (AV) block prompted a review of the medical literature to determine the prognosis for recovery of AV conduction or need for pacemaker implantation. A total of 40 patients younger than 20 years of age were identified, with return of AV conduction within 7 days in 27 patients (67%), permanent pacing in 11 patients (28%) with persistent AV block, and death in 2 patients (5%).     

A Cluster of Fulminant Myocarditis Cases in Children,Baltimore, Maryland, 1997

The true incidence of myocarditis in children is difficult to estimate because many mild cases go undetected. This study describes an unusual cluster of myocarditis cases that occurred in young children living in the greater Baltimore area between May and October 1997. A search of multiple comprehensive databases and interviews with area pediatric cardiologists were conducted to identify unreported cases and determine the background rate of myocarditis in the area. Seven cases of myocarditis were found as well as two with a similar clinical picture and myocardial fibrosis on tissue examination. Six case patients with active myocarditis and one child with fibrosis died. The case children were predominantly black (eight of nine) and male (seven of nine), with no identifiable risk factors. The disease was characterized by a fulminant course with malignant arrhythmias. The greatest number of pediatric myocarditis deaths reported in 1 year prior to 1997 was three. Myocardial tissues were examined using immunohistochemistry, in situ hybridization, and polymerase chain reaction but no etiologic agent was identified. This outbreak is unusual because of both the number of cases and the fulminant course of the disease in this group of children.     

小儿病毒性心肌炎与柯萨奇B组病毒抗体的关系探讨

目的探讨柯萨奇 Ｂ组病毒抗体ＩｇＭ测定在心肌炎病原学诊断和临床诊断中的意义。方法１９９６～１９９８年儿科住院病人７０例,分为心肌炎组２０例,疑似心肌炎组２５例,对照组２５例。用间接酶联免疫吸附法（ＥＬＩＳＡ）测定柯萨奇Ｂ组病毒抗体ＩｇＭ和ＩｇＧ。结果柯萨奇Ｂ组病毒抗体ＩｇＭ阳性心肌炎组１１例（５５％）,疑似心肌炎组１１例（４４％）,对照组１１例（４４％）,经统计学处理,其差别无显著性意义。结论用ＥＬＩＳＡ法测定柯萨奇Ｂ组病毒抗体ＩｇＭ,阳性提示有柯萨奇Ｂ组病毒感染,对心肌炎患儿可以作出病因和病原学诊断,但不能以此作为临床诊断心肌炎的依据。     

小儿病毒性心肌炎与柯萨奇B组病毒抗体的关系探讨

目的 探讨柯萨奇B组病毒抗体IgM测定在心肌炎病原学诊断和临床诊断中的意义。方法 1996～1998年儿科住院病人70例,分为心肌炎组20例,疑似心肌炎组25例,对照组25例。用间接酶联免疫吸附法(ELISA)测定柯萨奇B组病毒抗体IgM和IgG。 结果柯萨奇B组病毒抗体IgM阳性心肌炎组11例(55%),疑似心肌炎组11例(44%),对照组11例(44%),经统计学处理,其差别无显著性意义。结论 用ELISA法测定柯萨奇B组病毒抗体IgM,阳性提示有柯萨奇B组病毒感染,对心肌炎患儿可以作出病因和病原学诊断,但不能以此作为临床诊断心肌炎的依据。     

病毒性心肌炎小鼠心肌细胞凋亡和坏死的研究

目的： 探讨病毒性心肌炎小鼠心肌细胞的凋亡与坏死之间的相互关系。方法：　用4周龄Balb/c雄性小鼠腹腔接种柯萨奇B3病毒 (CVB3)制成病毒性心肌炎小鼠模型 ,采用膜联蛋白V联合PI染色双参数技术(AnnexinV/PI)在流式细胞仪上定量检测心肌细胞的凋亡和坏死。结果：　病毒性心肌炎小鼠心肌细胞的凋亡百分率和坏死百分率均显著高于正常对照小鼠(P<0.01),并且心肌细胞凋亡百分率及坏死百分率均与心肌病理积分呈正相关(r =0.70 ,P<0.01和r=0.93,P<0.01)。结论：　病毒性心肌炎小鼠同时存在着心肌细胞的凋亡和坏死 ,两者均与心肌病理损害程度密切相关,为病毒性心肌炎的重要病理过程     

Juvenile Churg-Strauss Syndrome as an Etiology of Myocarditis and Ischemic Stroke in Adolescents; a Case Report

Background

Churg-Strauss syndrome (CSS), a systemic vasculitis accompanied by asthma and eosinophilia, almost invariably affects the lung and is frequently associated with cutaneous involvement. It rarely has cardiac involvement. We report an unusual case of CSS with myocardial involvement and stroke.

Case Presentation

A 16-year old female suffered of allergic asthma for 4 years. She was under treatment with oral prednisolone and seretide inhalation. After CSS diagnosis, she developed paroxysmal atrial tachycardia. Serum levels of Troponin I and Troponin T were increased indicating massive myocardial damage probably due to myocarditis. After 5 months she developed acute hemiparesis without any evidence of ischemic or hemorrhagic event. She was treated with IVIg, intravenous pulses of methylprednisone and cyclophosphamide for each complication.

Conclusion

Myocarditis and stroke may also complicate CSS which should be taken in consideration for better management.     

PCR测定血中柯萨奇病毒B RNA对确定病毒性心肌炎病原诊断的价值

目的 研究PCR技术测血中柯萨奇病毒B RNA(CVB-RNA)对病毒性心肌炎病毒病原诊断的价值及其阳性率与病程的关系。方法 对75只小鼠腹腔注射CVB3病毒后,做心肌病理检查和检测血液中CVB-RNA。对145例临床诊断心肌炎患儿测定血中CVB-RNA,对比病毒性心肌炎患儿病程1个月以内104例和病程1个月以上41例的阳性率。结果 75只小鼠病理检查结果有心肌炎改变占85.3%,CVB-RNA阳性率为53.3%。145例患儿CVB-RNA阳性率为46.2%。PCR CVB-RNA病程1个月以内阳性率为56.7%,显著高于病程1个月以上(阳性率为26.8%)。结论 用PCR技术检测病毒性心肌炎血中CVB-RNA的敏感性与可靠性均较高,病程1个月以内阳性率高于1个月以上。     

PCR测定血中柯萨奇病毒B RNA对确定病毒性心肌炎病原诊断的价值

目的 研究PCR技术测血中柯萨奇病毒B RNA(CVB-RNA)对病毒性心肌炎病毒病原诊断的价值及其阳性率与病程的关系。方法 对75只小鼠腹腔注射CVB3病毒后,做心肌病理检查和检测血液中CVB-RNA。对145例临床诊断心肌炎患儿测定血中CVB-RNA,对比病毒性心肌炎患儿病程1个月以内104例和病程1个月以上41例的阳性率。结果 75只小鼠病理检查结果有心肌炎改变占85.3%,CVB-RNA阳性率为53.3%。145例患儿CVB-RNA阳性率为46.2%。PCR CVB-RNA病程1个月以内阳性率为56.7%,显著高于病程1个月以上(阳性率为26.8%)。结论 用PCR技术检测病毒性心肌炎血中CVB-RNA的敏感性与可靠性均较高,病程1个月以内阳性率高于1个月以上。     

NT-proBNP as a Marker for Persistent Cardiac Disease in Children with History of Dilated Cardiomyopathy and Myocarditis

Children with myocarditis and dilated cardiomyopathy may recover clinically and echocardiographically. Plasma levels of the N-terminal segment of B-type natriuretic peptide prohormone (NT-proBNP), a sensitive marker for cardiac dysfunction, may reflect residual cardiac damage in these patients. The purpose of this study was to evaluate NT-proBNP status in pediatric patients with a history of myocarditis and dilated cardiomyopathy. Cardiac evaluation was performed and the levels of NT-proBNP were measured in 23 children who had a history of myocarditis or dilated cardiomyopathy. NT-proBNP levels were also measured in 56 age-matched control children. Nine of the 23 patients had evidence of left ventricular dysfunction (DCM group), whereas 14 had none (recovery). NT-proBNP levels were higher in the DCM group (3154 ± 2858 pg/ml) than in the recovery group (122 ± 75 pg/ml, p < 0.001) and the control group (113 ± 96 pg/ml, p < 0.001). There was no difference between the recovery and the control groups (p = 0.45), and none of the recovered patients had a NT-proBNP level higher than the upper limit of normal. The area under the receiver operating characteristics curve for the diagnosis of persistent left ventricular dysfunction was 0.984. NT-proBNP levels correlated with echocardiographically derived shortening fraction and with clinical score. NT-proBNP is a good marker for persistent left ventricular dysfunction in children who have had myocarditis or cardiomyopathy. In this group of patients, NT-proBNP levels are normal in children who recover echocardiographically, suggesting no residual hemodynamic abnormalities.