Immunoadsorption therapy for a meningococcemia patient with myocarditis, adrenal hemorrhage, and purpura fulminans: a case report

Abstract Neisseria meningitidis, also known as meningococcus, is a relatively uncommon cause of invasive infection, but when it occurs, it is frequently severe and potentially life-threatening. A ten-year-old female patient developed a purpuric rash with fever. Upon arrival to the pediatric intensive care department, she was unconscious and in a poor general condition. We combined treatment with antibiotics, volume resuscitation, hydrocortisone, and CytoSorb® therapy resulted in a stabilization of hemodynamics, as well as control of hyperinflammation. We observed a significant decrease in vasopressor dosage in this patient.

Predictive Value of Myocardial injury in Patients with COVID-19 Admitted to a Quaternary Hospital in the City of Rio de Janeiro

Abstract Background In Brazil the factors involved in the risk of death in patients with COVID-19 have not been well established. Objective To analyze whether elevations of high-sensitivity troponin I (hTnI) levels influence the mortality of patients with COVID-19. Methods Clinical and laboratory characteristics of hospitalized patients with COVID-19 were collected upon hospital admission. Univariate and binary logistic regression analyzes were performed to assess the factors that influence mortality. P-value<0.05 was considered significant. Results This study analyzed192 patients who received hospital admission between March 16 and June 2, 2020 and who were discharged or died by July 2, 2020. The mean age was 70±15 years, 80 (41.7%) of whom were women. In comparison to those who were discharged, the 54 (28.1%) who died were older (79±12 vs 66±15years; P=0.004), and with a higher Charlson´s index (5±2 vs 3±2; P=0.027). More patients, aged≥60years (P <0.0001), Charlson´s index>1 (P=0.004), lung injury>50% in chest computed tomography (P=0.011), with previous coronary artery disease (P=0.037), hypertension (P=0.033), stroke (P=0.008), heart failure (P=0.002), lymphocytopenia (P=0.024), high D-dimer (P=0.024), high INR (P=0.003), hTnI (P<0.0001), high creatinine (P<0.0001), invasive mechanical ventilation (P<0.0001), renal replacement therapy (P<0.0001), vasoactive amine (P<0.0001), and transfer to the ICU (P=0.001), died when compared to those who were discharged. In logistic regression analysis, elevated hTnI levels (OR=9.504; 95% CI=1.281-70.528; P=0.028) upon admission, and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360-923.706; P=0.012) increased the chance of in-hospital mortality. Conclusion This study suggests that in COVID-19 disease, myocardial injury upon hospital admission is a harbinger of poor prognosis.

Cardiovascular Risk Assessment after COVID-19 Infection before Resuming Sports Activities - Practical Flowchart and Meta-Analysis

Abstract Background: The risk of sports-related sudden cardiac arrest after COVID-19 infection can be a serious problem. There is an urgent need for evidence-based criteria to ensure patient safety before resuming exercise. Objective: To estimate the pooled prevalence of acute myocardial injury caused by COVID-19 and to provide an easy-to-use cardiovascular risk assessment toolkit prior to resuming sports activities after COVID-19 infection. Methods: We searched the Medline and Cochrane databases for articles on the prevalence of acute myocardial injury associated with COVID-19 infection. The pooled prevalence of acute myocardial injury was calculated for hospitalized patients treated in different settings (non-intensive care unit [ICU], ICU, overall hospitalization, and non-survivors). Statistical significance was accepted for p values <0.05. We propose a practical flowchart to assess the cardiovascular risk of individuals who recovered from COVID-19 before resuming sports activities. Results: A total of 20 studies (6,573 patients) were included. The overall pooled prevalence of acute myocardial injury in hospitalized patients was 21.7% (95% CI 17.3-26.5%). The non-ICU setting had the lowest prevalence (9.5%, 95% CI 1.5-23.4%), followed by the ICU setting (44.9%, 95% CI 27.7-62.8%), and the cohort of non-survivors (57.7% with 95% CI 38.5-75.7%). We provide an approach to assess cardiovascular risk based on the prevalence of acute myocardial injury in each setting. Conclusions: Acute myocardial injury is frequent and associated with more severe disease and hospital admissions. Cardiac involvement could be a potential trigger for exercise-induced clinical complications after COVID-19 infection. We created a toolkit to assist with clinical decision-making prior to resuming sports activities after COVID-19 infection.

COVID-19 and acute myocarditis: current literature review and diagnostic challenges

SUMMARY INTRODUCTION In the current literature, there has been an upsurge of cases of COVID-19-induced acute myocarditis. In this case-based review, we aimed to describe the clinical characteristics, imaging findings, and in-hospital course of acute myocarditis. In addition, the limitations of the myocarditis diagnosis were discussed since only fulminant myocarditis cases have been mentioned in the current literature. METHODS We performed a review of the literature of all patients who were diagnosed with COVID-19-induced acute myocarditis using the databases of PubMed, Embase, and the Cochrane. RESULTS 16 case reports were found to be related to COVID-19-induced acute myocarditis. We observed that the ECG findings in most of the COVID-19 patients were non-specific, including diffuse ST-segment elevation, non-specific intraventricular conduction delay, sinus tachycardia, and inverted T-waves in anterior leads. Echocardiographic findings of COVID-19-induced acute myocarditis patients ranged from preserved left ventricular ejection fraction (LVEF) without segmental abnormalities to reduced LVEF with global hypokinesia. Interestingly, a few patients with COVID-19-induced acute fulminant myocarditis were steroid-responsive and had an amelioration with glucocorticoid and immunoglobulin therapy. CONCLUSION Despite the COVID-19 pandemic worldwide, a limited number of cases has been shared in the current literature. There are a lot of difficulties in the differential diagnosis of acute myocarditis in the context of COVID-19.

RESUMO INTRODUÇÃO Na literatura atual, houve um aumento dos casos apresentados com doença coronavírus de 2019 (COVID-19) induzida por miocardite aguda. Nesta revisão baseada em casos, buscamos descrever as características clínicas, achados de imagem e curso hospitalar de miocardite aguda. Além disso, as limitações em relação ao diagnóstico de miocardite foram discutidas, uma vez que apenas casos de miocardite fulminante foram mencionados na literatura atual. MÉTODOS Fizemos uma revisão da literatura de todos os pacientes diagnosticados com miocardite aguda induzida por COVID-19 com a utilização das bases de dados PubMed, Embase e Cochrane. RESULTADO Dezesseis casos relatados estão relacionados com a miocardite aguda induzida pela COVID-19. Observamos que os achados de ECG na maioria dos pacientes com COVID-19 não eram específicos, incluindo elevação difusa do segmento ST, atraso não específico da condução intraventricular, taquicardia sinusal e ondas T invertidas em pistas anteriores. Os resultados ecocardiográficos de doentes com miocardite aguda COVID-19 variaram entre a fração de ejeção ventricular esquerda preservada (LVEF) sem anomalias segmentais e a LVEF reduzida com hipocinésia global. Curiosamente, alguns pacientes com COVID-19 induzidos à miocardite aguda fulminante eram sensíveis aos esteroides e tinham uma melhoria com glucocorticoides e terapia com imunoglobulina. CONCLUSÃO Apesar da pandemia de COVID-19 em todo o mundo, um número limitado de casos tem sido compartilhado na literatura atual. Há muitas dificuldades para o diagnóstico diferencial de miocardite aguda no contexto da COVID-19.

Giant cell myocarditis causing sudden death in a patient with sarcoidosis

Giant cell myocarditis (GCM) is a rare and rapidly fatal cardiovascular condition most often seen in young adults. It is characterized microscopically by myocardial necrosis with multinucleated giant cells in the absence of well-defined granulomas. This disorder has typically been attributed to manifest as heart failure, but in some individuals, GCM may present as sudden cardiac death. Herein, we present a fatal case of GCM in a 36-year-old male with a history of autoimmune disorders. The decedent presented to the emergency room due to vomiting and was treated for nausea due to suspected dehydration. He was discharged that night and found dead on his bathroom floor the following day. Postmortem examination revealed psoriasis and granulomatous lesions in the lungs consistent with sarcoidosis, further supporting circumstantial evidence existing between GCM and autoimmune disorders. Additionally, this case provides an opportunity to distinguish GCM from the distinct clinical entity of cardiac sarcoidosis (CS), especially in the setting of systemic sarcoidosis. We hope to raise awareness of this rare disease process and its potential to cause sudden cardiac death so that it may be considered in a differential diagnosis as immunosuppression and early cardiac transplantation largely determine the prognosis.

Evolutive study of rheumatic carditis cases treated with corticosteroids in a Public Hospital / Estudo evolutivo de casos de cardite reumática tratados com corticosteróides em um hospital público

Background: Rheumatic carditis is a challenge for treatment and secondary prophylaxis, due to severe valve sequelae. Objective: To evaluate the cases of rheumatic carditis in patients under 18 years old treated with corticosteroids.Methods: An observational, longitudinal and retrospective study was carried out on the profile of patients, in the period of 2000-2015. We selected those who received corticosteroid therapy at immunosuppressive doses, for the treatment of carditis and were aged 5 to 18 years. Data were extracted from medical records. Calculations of: averages, standard deviations, medians and interquartile ranges, ratios and 95% confidence intervals were obtained. Chi-square and Wilcoxon tests were applied for comparisons. The level of significance was 5%. Results: Of the 93 cases, 93.53% developed moderate or severe carditis. Mitral regurgitation was detected in 100% of the sample. Pulse therapy was administered in 11.83%. Surgery was performed in 23.69% of patients: mitral, aortic and/or tricuspid valve repair or replacement. The evolution of the cases was favorable in 70.96%. There was a good response among those who received only clinical treatment and those who belonged to the surgical group. The comparison of the initial and posterior valve lesions to the corticoid use was statistically significant (p < 0.001). A difference between the ejection fraction medians was observed (p = 0.048). Hospitalization was required twice or more for 45.16% of the patients. The mortality rate was 5.38%.Conclusions: The patients showed significant clinical improvement. The treatment was effective, reducing trivalvular impairment

Ictus isquémico masivo secundario a miocarditis viral en un niño / Massive ischemic stroke secondary to viral myocarditis in a child

Introducción: los accidentes cerebrovasculares son raros en niños, y generalmente se asocian a trombofilias; sin embargo, se deben considerar procesos infecciosos de tipo miocarditis infecciosa que pudieran conducir a formación de trombos. Presentación del caso: se presenta el caso de un niño de 13 meses de edad, previamente sano, con evidencia de accidente cerebrovascular isquémico extenso, que comprometió ambos hemisferios cerebrales, con antecedente de infección gastrointestinal que podría sugerir sepsis y miocarditis secundaria a esta, que contribuye a un evento trombótico, el cual, probablemente, desencadenó el proceso cerebrovascular descrito. Conclusiones: las infecciones, aunque se han relacionado como la tercera causa de eventos cerebrovasculares, se deben tener en cuenta para así instaurar tratamiento antibiótico oportuno, y con esto, evitar secuelas(AU)

Introduction: cerebrovascular accidents are rare in children, and they are generally associated with thrombophilia. However, infectious processes such as myocarditis should also be considered, for they may lead to thrombus formation. Case presentation: a previously healthy 13-month-old male child presents with evidence of extensive ischemic cerebrovascular accident compromising both cerebral hemispheres, with a history of gastrointestinal infection which might suggest the presence of sepsis and myocarditis secondary to it contributing to a thrombotic event which probably triggered the cerebrovascular process herein described. Conclusions: although they have been ranked as the third cause of cerebrovascular events, infections should be taken into account so as to timely indicate the appropriate antibiotic treatment and avoid the occurrence of sequels(AU)

Pathological Substratum for a Case of Fulminant Myocarditis Treated with Extracorporeal Membrane Oxygenation and Subsequent Heart Transplantation

Fulminant myocarditis has been defined as the clinical manifestation of cardiac inflammation with rapid-onset heart failure and cardiogenic shock. We report on the case of a 23-yr-old woman with pathology-proven fulminant lymphocytic myocarditis presenting shock with elevated cardiac troponin I and ST segments in V1-2, following sustained ventricular tachycardia and a complete atrioventricular block. About 55 min of intensive cardio-pulmonary resuscitation, with extracorporeal membrane oxygenation support, bridged the patient to orthotopic heart transplantation. The explanted heart revealed diffuse lymphocytic infiltration and myocyte necrosis in all four cardiac chamber walls. Aggressive mechanical circulatory support may be an essential bridge for recovery or even transplantation in patients with fulminant myocarditis with shock.

Taquicardia ventricular de dificil controle em caso atípico de miocardite com acometimento de ventrículo direito / Hard-to-control ventricular tachycardia in an unusual case of myocarditis with involvement of the right ventricle

A apresentação clínica da miocardite varia desde casos assintomáticos a episódios de morte súbita. Nossintomáticos, a insuficiência cardíaca é a manifestação mais frequente. Arritmias, bloqueios cardíacos e clínica sugestiva de síndrome coronariana podem ocorrer. A diversidade da apresentação clínica, somada à dependência da biopsia miocárdica, torna o diagnóstico um desafio. Novos métodos, como a ressonância miocárdica (RM), estão adquirindo grande importância,auxiliando na investigação dos casos suspeitos. Os autores relatam um caso de taquiarritmia ventricular de difícil controle e com foco sugestivo em ponta de ventrículo direito. Miocardite foi a hipótese diagnóstica, confirmada pela RM.

Insuficiência cardíaca secundária a lúpus eritematoso sistêmico / Heart failure secondary to systemic lupus erythematosus

O lúpus eritematoso sistêmico (LES) é uma doença sistêmica, de etiologia desconhecida e multifatorial. Está associado a diversas manifestações cardiovasculares como aterosclerose acelerada, pericardite, miocardite, valvulopatias, endocardite de Libman-Sacks, entre outras, contribuindo para a morbidade e mortalidade dos pacientes. Conclui-se, então, que tal colagenose deverá ser lembrada como causa de cardiomiopatia.

Systemic lupus erythematosus (SLE) is a multifactorial systemic disease of unknown etiology. It is associated with several cardiovascular manifestations, such as accelerated atherosclerosis, pericarditis, myocarditis, valvulopathies and Libman-Sacks endocarditis, amongothers, contributing to patient morbidity and mortality. It thus follows that this collagenosis should be recalled as a cause of cardiomyopathy.

Cardiomiopatia dilatada por virus H1N1 / Dilated cardiomyopathy due to H1N1 virus

Mulher de 58 anos, sem antecedentes médicos relevantes, apresenta infecção respiratória pelo vírus H1N1, requerendo internação na Unidade de Cuidados Intensivos. Após a alta, refere progressiva astenia e dispneia, sendo internada nove meses depois por derrame pleural e infecção respiratória. Avaliação específica pela Cardiologia revela cardiomiopatia dilatada com má função sistólica do ventrículo esquerdo, compatível com miocardite. A ressonância magnética se apresenta compatível com miocardite. Dados os antecedentes e havendo sido descartada doença autoimune e tóxica, associou-se a doença ao vírus H1N1. O prognóstico é muito positivo, com recuperação quase total da função do ventrículo esquerdo.

A 58-year-old woman with no relevant prior medical conditions presented a respiratory infection caused by theH1N1 virus, requiring admittance to an Intensive Care Unit. After discharge, the patient complained of progressiveasthenia and dyspnea, being hospitalized nine months later with a diagnosis of pleural effusion and respiratory infection. Further evaluation by the Cardiology Unit revealed dilated cardiomyopathy with poor systolicfunction of the left ventrícle, compatible with myocarditis. A cardiac magnetic ressonance examination was compatible with myocarditis. Given her previousadmittance and having ruled out toxic aspects and autoimmune disease, the disease was associated with the H1N1 virus. The prognosis is very positive, with almost complete recovery of the left ventricular function.

The expressions of HSP70 and alphaB-crystallin in myocarditis associated with foot-and-mouth disease virus in lambs

This study describes the expression of heat shock protein70 (HSP70) and alpha-basic-crystallin (alpha-BC) and their association with apoptosis and some related adaptor proteins in the pathogenesis of foot-and-mouth disease virus (FMDV)-induced myocarditis in lambs. HSP70 was generally overexpressed in the myocardial tissues and inflammatory cells of FMDV-induced myocarditis with differential accumulation and localization in same hearts when compared to non-foot-and-mouth disease control hearts. alpha-BC immunolabeling showed coarse aggregations in the Z line of the cardiomyocytes in FMDV-infected hearts in contrast to control hearts. Overall, the results of this study show that the anti-apoptotic proteins, HSP70 and alpha-BC, were overexpressed with increased apoptosis in FMDV-infected heart tissues. Both proteins failed to protect the cardiomyocytes from apoptosis as defense mechanisms to the FMDV during the infection, suggesting that the virus is able to increase apoptosis via both downregulation and/or upregulation of these anti-apoptotic proteins.