Anakinra treats fulminant myocarditis from Neisseria meningitidis septicaemia and haemophagocytic lymphohistiocytosis: a case report

Treatment of pediatric severe acute myopericarditis with anakinra: a case report and literature review

Acute myocarditis (AM) is an inflammation of the myocardium with a rapid onset of typically <1 month. The use of anakinra (ANK) for treating inflammatory AM in adults has been recently described; however, while some reports are promising, its efficacy remains debated. Here, we present a case of severe AM with concomitant systemic symptoms [fever, elevated C-reactive protein (CRP)] in a pediatric patient who was successfully treated with high-dose ANK. A literature review of similar published cases is also presented. A 14-year-old boy was admitted for AM with concomitant pericarditis. At disease onset, the patient presented with high fever and elevated CRP (163 mg/L) and troponin I (14,816 ng/L). Treatment with ibuprofen (30 mg/kg/day), intravenous immunoglobulin (80 g in 24 h), and colchicine (0.5 mg per day) were initiated without benefit and with further worsening of contractile function [Ejection Fraction (EF) 26%]. Consequently, inotropic support and intravenous methylprednisolone were started, leading to a partial improvement of EF (45%). Due to the inability to reduce inotropic support, a rescue treatment with ANK (7 mg/kg/day) in continuous intravenous infusion was started, resulting in progressive improvement and normalization of left ventricular systolic function. Our literature review identified five case reports of pediatric AM successfully treated with ANK. Most cases presented elevated inflammatory markers (ferritin and CRP) and/or concomitant pericarditis. We conclude that ANK, especially at high doses, may be useful for treating severe pediatric AM, particularly when associated with severe inflammation and/or pericarditis.

Infectious factors in myocarditis: a comprehensive review of common and rare pathogens

BACKGROUND

Myocarditis is a significant health threat today, with infectious agents being the most common cause. Accurate diagnosis of the etiology of infectious myocarditis is crucial for effective treatment.

MAIN BODY

Infectious myocarditis can be caused by viruses, prokaryotes, parasites, and fungi. Viral infections are typically the primary cause. However, some rare opportunistic pathogens can also damage heart muscle cells in patients with immunodeficiencies, neoplasms and those who have undergone heart surgery.

CONCLUSIONS

This article reviews research on common and rare pathogens of infectious myocarditis, emphasizing the complexity of its etiology, with the aim of helping clinicians make an accurate diagnosis of infectious myocarditis.

CLINICAL UTILITY OF INTERLEUKIN-1 INHIBITORS IN PEDIATRIC SEPSIS

ABSTRACT

The pathophysiology of pediatric sepsis is characterized by increased innate immune activation earlier in life. Interleukin-1 is a proinflammatory cytokine implicated in the pathophysiology of sepsis, and ferritin is a stable surrogate biomarker for elevated IL-1 levels. Data in adult sepsis have shown that use of anakinra, an anti-IL-1 receptor antagonist, led to improved clinical outcomes in patients with features of macrophage activation and hyperferritinemia. However, data in pediatric sepsis are lacking. Our narrative review sought to highlight the current understanding of using IL-1 inhibitors in pediatric sepsis. We identified five studies including one case report and four retrospective case series that described clinical outcomes in relation to use of anakinra for secondary hemophagocytic lymphohistiocytosis (HLH). A few patients in this pooled heterogenous cohort of 72 patients had concomitant infection meeting the criteria for sepsis. All studies measured ferritin levels and reported a decrease in ferritin after initiating anakinra. Twelve patients died after treatment initiation. There was no clear comparison in clinical outcomes between infected and noninfected patients. The pathophysiology of pediatric sepsis suggests that there is a need for blinded clinical trials using targeted immunomodulation such as IL-1 inhibitors in pediatric sepsis cohort with an immunophenotype suggesting increased innate immune activation.