Acute myocarditis is an inflammatory disease of the heart mostly diagnosed in young people, which can present as sudden death. The etiology includes infectious agents (mostly viruses), systemic diseases and toxins. We aim to characterize infants and children with myocarditis at post-mortem presenting as sudden deaths.
Methods
Retrospective evaluation of 813 post-mortems in infants and children dying suddenly and unexpectedly between 2009–2019. Data retrieved included histological features, microbiology and clinical history.
Results
23 of 813 post-mortems reviewed corresponded to acute myocarditis and 1 to dilated cardiomyopathy related to remote Parvovirus infection. PCR identified enterovirus (7), parvovirus (7 cases, 2 also with HHV6 and 1 case with EVB), Influenza A (1), Parainfluenza type 3 (1). Two cases corresponded to hypersensitivity myocarditis, 1 was Group A Streptococcus and 5 idiopathic myocarditis. Enterovirus was frequent in infants (7/10), and in newborns was associated with meningoencephalitis or congenital myocarditis. More than 50% were less than 2 years of age and all remained clinically unsuspected.
Conclusion
Myocarditis represents almost 3% of all sudden pediatric deaths. Enterovirus and parvovirus were the most common viruses. This retrospective analysis showed that patients experienced viral symptoms but remained unsuspected, highlighting the need for more clinical awareness of myocarditis.
Thomas AretzH.Myocarditis: the Dallas criteria. Hum Pathol. 1987;
18(6):619–624.
4.
LeoneOVeinotJPAngeliniA, et al.
2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology.Cardiovasc Pathol. 2012;
21(4):245–274.
JasraSKBadianCMacriIRaP.Recognition of early myocardial infarction by immunohistochemical staining with cardiac troponin-I and complement C9. J Forensic Sci. 2012;
57(6):1595–600.
8.
NguyenYRenoisFLevequeN, et al.
Virus detection and semiquantitation in explanted heart tissues of idiopathic dilated cardiomyopathy adult patients by use of PCR coupled with mass spectrometry analysis. J Clin Microbiol. 2013;
51(7):2288–2294.
MagnaniJWDecGW.Myocarditis: current trends in diagnosis and treatment.Circulation. 2006;
113(6):876–890.
11.
WeberMAAshworthMTRisdonRA, et al,
Clinicopathological features of paediatric deaths due to myocarditis: an autopsy series.Arch Dis Child. 2008;
93(7):594–598.
12.
LevineMCKlugmanDTeachSJ.Update on myocarditis in children.Curr Opin Pediatr. 2010;
22(3):278–283.
13.
DennertRCrijnsHJHeymansS.Acute viral myocarditis.Eur Heart J. 2008;
29(17):2073–2082
14.
CaforioALPPankuweitSArbustiniE, et al.
Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.Eur Heart J. 2013;
34(33):2636–2648.
CanterCESimpsonKP.Diagnosis and treatment of myocarditis in children in the current era.Circulation. 2014;
129 (1):115–128.
17.
VigneswaranTVBrownJRBreuerJBurchM.Parvovirus B19 myocarditis in children: an observational study.Arch Dis Child. 2016;
101(2):177–180.
18.
KühlUPauschingerMNoutsiasM, et al.
High prevalence of viral genomes and multiple viral infections in the myocardium of adults with “idiopathic” left ventricular dysfunction.Circulation. 2005;
111(7):887–893.
19.
DaviesMJMcKennaWJ.Introduction to pathology and pathogenesis. Heart. 1994;
72:S2–S3.
20.
VerdonschotJHazebroekMMerkenJ, et al.
Relevance of cardiac parvovirus B19 in myocarditis and dilated cardiomyopathy: review of the literature.Eur J Heart Fail. 2016;
18(12):1430–1441.
21.
MolinaKMGarciaXDenfieldSW, et al.
Parvovirus B19 myocarditis causes significant morbidity and mortality in children.Pediatr Cardiol. 2013;
34(2):390–397.
22.
Khediri Z, Vauloup-Fellous C, Benachi A, Ayoubi JM, Mandelbrot L, Picone O.
Adverse effects of maternal enterovirus infection on the pregnancy outcome: a prospective and retrospective pilot study.Virol J. 2018;
15(1):70.
23.
Inwald D, Franklin O, Cubitt D, Peters M, Goldman A, Burch M.
Enterovirus myocarditis as a cause of neonatal collapse. Arch Dis Child Fetal Neonatal Ed. 2004;
89(5):461–463.
24.
Dettmeyer R, Baasner A, Schlamann M, Haag C, Madea B.
Teaching case coxsackie B3 myocarditis in 4 cases of suspected sudden infant death syndrome: diagnosis by immunohistochemical and molecular-pathologic investigations. Pathol Res Pract. 2002;
198:689–696.
25.
KadambariSBraccioSRibeiroS, et al.
Enterovirus and parechovirus meningitis in infants younger than 90 days old in the UK and Republic of Ireland: a British Paediatric Surveillance Unit study. Arch Dis Child. 2019;
104(6):552–557.
26.
BowlesNENiJKearneyDL, et al.
Detection of viruses in myocardial tissues by polymerase chain reaction. Evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol. 2003;
42(3):466–472.
27.
AykacKOzsurekciYKahyaogluP, et al.
Myocarditis associated with influenza infection in five children.J Infect Public Health. 2018;
11(5):698–701.
28.
MooreDLVaudryWScheifeleDW, et al.
Surveillance for influenza admissions among children hospitalized in Canadian immunization monitoring program active centers, 2003-2004. Pediatrics. 2006;
118(3):e610–e619.
29.
Romero-GómezMPGueretaLPareja-GrandeJ, et al.
Myocarditis caused by human parainfluenza virus in an immunocompetent child initially associated with 2009 influenza A (H1N1) virus.J Clin Microbiol. 2011;
49(5):2072–2073.
30.
Aranda CazónCArruza GómezLHerranz CarrilloG, et al.
Parainfluenza 3 respiratory infection associated with pericardial effusion in a very low birthweight infant. Case Rep Infect Dis. 2017;
2017:1–4.
31.
ParkYAhnSGKoA, et al. Hypersensitivity myocarditis confirmed by cardiac magnetic resonance imaging and endomyocardial biopsy. Korean J Intern Med. 2014;
29(2):236–240.
32.
LewinDd’AmatiGLewisW.Hypersensitivity myocarditis: findings in native and transplanted hearts. Cardiovasc Pathol. 1992;
1:225–229.
33.
KlionA.Hypereosinophilic syndrome: approach to treatment in the era of precision medicine.Hematology. 2018;
2018(1):326–331.
34.
Sheikh H, Siddiqui M, Uddin SMM, Haq A, Yaqoob U
. The clinicopathological profile of eosinophilic myocarditis. Cureus. 2018;
10(12):e3677.
35.
Cheung CC, Constantine M, Ahmadi A, Shiau C, Chen LYC.
Eosinophilic myocarditis.Am J Med Sci. 2017;
354(5):486–492.
36.
Andréoletti L, Lévêque N, Boulagnon C, Brasselet C, Fornes P.
Viral causes of human myocarditis. Arch Cardiovasc Dis. 2009;
102(6–7):559–568.
