Not every fulminant lymphocytic myocarditis fully recovers

The Possible Role of IVIG in the Treatment of Atrial Fibrillation Accompanied by Fulminant Myocarditis in a 12-Year-Old Pediatric Patient

Background

Fulminant myocarditis (FM) is a potentially lethal condition in children due to rapid progressive hemodynamic instability and cardiogenic shock. Patients with FM might show different clinical manifestations on emergency department admission.

Case

Herein, we describe the case of a 12-year-old girl who was admitted to our institution's emergency department due to complaints of abdominal pain and incessant vomiting. However, we detected an early onset of atrial fibrillation (AF) accompanied by FM. The patient's condition of AF and severe hemodynamic disorder was successfully treated in our institution's pediatric intensive care unit.

Conclusion

To the best of our knowledge, this is the first report of the co-occurrence of FM and AF successfully treated in childhood. This case report will serve as a guide for the treatment of cases with FM accompanied by AF.

Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes

Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.

Early characteristics of fulminant myocarditis vs non-fulminant myocarditis: A meta-analysis

BACKGROUND

Fulminant myocarditis (FM) is a sub-category myocarditis. Its primary characteristic is a rapidly progressive clinical course that necessitates hemodynamic support. FM can be difficult to predict at the onset of myocarditis. The aim of this meta-analysis was to identify the early characteristics in FM compared to those of non-fulminant myocarditis (NFM).

METHODS

We searched the databases of MEDLINE, EMBASE, CENTRAL, for studies comparing FM with acute NFM from January 1, 2000 to June 1, 2018. The baseline variables were compared in each study. Mean differences (MD) and relative ratios (RR) were calculated.

RESULTS

Seven studies (158 FM patients and 388 NFM patients) were included in the analysis. The FM group had significantly lower systolic blood pressure (SBP), higher creatine kinase (CK), wider QRS duration, lower left ventricular ejection fraction (LVEF), thicker left ventricular posterior wall diameter (LVPWd), higher incidence of ST depression, ventricular tachycardia/ventricular fibrillation (Vt/Vf) and syncope, less incidence of chest pain than the NFM groups. There was no difference in terms of heart rate (HR), c-reactive protein (CRP), fever, dyspnea, white blood cells (WBC), atrioventricular block (AVB), Q waves, ST elevation, interventricular septum diameter (IVSd), or end-diastolic left ventricular diameter (LVEDd) between FM and NFM.

CONCLUSION

We found that the lower SBP, higher CK, wider QRS duration, lower LVEF, thicker LVPWd, higher incidence of ST depression, Vt/Vf and syncope as well as lower incidence of chest pain were early characteristics of FM.

Acute and Fulminant Myocarditis: a Pragmatic Clinical Approach to Diagnosis and Treatment

PURPOSE OF REVIEW

To review the clinical features of acute myocarditis, including its fulminant presentation, and present a pragmatic approach to the diagnosis and treatment, considering indications of American and European Scientific Statements and recent data derived by large contemporary registries.

RECENT FINDINGS

Patients presenting with acute uncomplicated myocarditis (i.e., without left ventricular dysfunction, heart failure, or ventricular arrhythmias) have a favorable short- and long-term prognosis: these findings do not support the indication to endomyocardial biopsy in this clinical scenario. Conversely, patients with complicated presentations, especially those with fulminant myocarditis, require an aggressive and comprehensive management, including endomyocardial biopsy and availability of advanced therapies for circulatory support. Although several immunomodulatory or immunosuppressive therapies have been studied and are actually prescribed in the real-world practice, their effectiveness has not been clearly demonstrated. Patients with specific histological subtypes of acute myocarditis (i.e., giant cell and eosinophilic myocarditis) or those affected by sarcoidosis or systemic autoimmune disorders seem to benefit most from immunosuppression. On the other hand, no clear evidence supports the use of immunosuppressive agents in patients with lymphocytic acute myocarditis, even though small series suggest a potential benefit. Acute myocarditis is a heterogeneous condition with distinct pathophysiological pathways. Further research is mandatory to identify factors and mechanisms that may trigger/maintain or counteract/repair the myocardial damage, in order to provide a rational for future evidence-based treatment of patients affected by this condition.