[Pheochromocytoma as a simulator of cardiac pathology]. / Feocromocitoma como simulador de patología cardiaca.

Pheochromocytomas are rare neuroendocrine tumors that can present as hypertensive crises or serious cardiac and cerebrovascular complications that endanger the patient's life. Two unusual cases of adrenergic crises induced by pheochromocytoma with cardiovascular manifestations are presented, one with multiple complications/multiorgan failure, fatal outcome and definitive diagnosis in the post mortem autopsy, and another with a satisfactory evolution after diagnosis and appropriate treatment.

Early unloading and clinical outcomes in patients with fulminant myocarditis undergoing VA-ECMO: results of a multicenter retrospective study.

INTRODUCTION AND OBJECTIVES: Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in patients with fulminant myocarditis, the most effective timing of venting is uncertain. We aimed to investigate the benefit of early venting among patients who underwent VA-ECMO for fulminant myocarditis. METHODS: Among 841 patients with acute myocarditis from 7 hospitals in the Republic of Korea, 217 patients with fulminant myocarditis who underwent VA-ECMO were included in this analysis. The patients were categorized into 2 groups: an early unloading group that underwent venting within 24hours of ECMO insertion, and the no or delayed unloading group. The primary outcome was a composite of death, cardiac replacement, or cardiovascular rehospitalization. RESULTS: Among 217 patients, 56 underwent early venting, 54 underwent delayed venting, and 107 did not undergo venting. On spline curves in 110 patients who underwent venting, rapid deterioration was observed as the timing of venting was delayed. The incidence of the primary outcome was lower in the early venting group than in the no or delayed unloading group (37.5% vs 58.4%; HR, 0.491; 95%CI, 0.279-0.863; P=.014). Among patients not experiencing the primary outcome within 6 months, clinical outcomes were similar after 6 months (P=.375). CONCLUSIONS: Early left heart unloading within 24hours of ECMO insertion is associated with a lower risk of a composite of death, cardiac replacement therapy, and cardiovascular rehospitalization in patients with fulminant myocarditis undergoing VA-ECMO. Registered at ClinicalTrials.gov (NCT05933902).

Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis.

Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.

Myocarditis related SARS-CoV-2 infection or vaccination: an expert consensus statement on its diagnosis and management.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has revealed several cardiovascular complications, including myocarditis caused by SARS-CoV-2 infection (COVID-19) or after messenger RNA vaccine administration. Because of the high prevalence of COVID-19, the expansion of vaccination programs, and the appearance of new information on myocarditis in these contexts, there is a need to condense the knowledge acquired since the start of the pandemic. To meet this need, this document was drafted by the Myocarditis Working Group of the Heart Failure Association of the Spanish Society of Cardiology, with the collaboration of the Spanish Agency for Medicines and Health Products (AEMPS). The document aims to address the diagnosis and treatment of cases of myocarditis associated with SARS-CoV-2 infection or messenger RNA vaccine administration.

Nuclear Cardiology in the COVID-19 pandemic.

SARS-CoV-2 infection has a very important relationship with cardiovascular disease. Since the beginning of the pandemic, a close relationship has been observed between cardiovascular comorbidity and a worse prognosis in COVID-19 patients. The study of the pathophysiology of SARS-CoV-2 infection and cardiovascular disease suggests several concomitant hypotheses: direct myocardial damage by the virus, hypoxemia secondary to respiratory failure, inflammatory response to infection and/or thromboembolic phenomena. Cardiovascular damage can manifest in the acute phase of infection with acute myocardial infarction, myocarditis, arrhythmias…, during this phase Nuclear Cardiology procedures have not played a determining role in the diagnosis and management of these patients. On the other hand, in the subacute phase of the infection and in the post-acute COVID syndrome, Nuclear Cardiology seems to shed light on what happens in the cardiovascular system in this phase of the disease. The COVID-19 pandemic has represented a great challenge for health systems, with a significant reduction in non-urgent diagnostic procedures with the aim of reducing the risk of transmission to patients and health personnel. Nuclear Cardiology has not been an exception. In addition to the prioritization of urgent/non-deferrable procedures and general screening, hygiene and distance measures, the main organizations and scientific societies of Nuclear Medicine and Nuclear Cardiology released recommendations and guidelines for safe practice, introducing significant changes in myocardial perfusion SPECT protocols.

Prevalence and pattern of myocardial involvement on cardiac magnetic resonance imaging in Takayasu arteritis and its relationship with disease activity.

BACKGROUND: Cardiac involvement in Takayasu arteritis (TA) is the major cause of morbidity and mortality. Cardiovascular magnetic resonance (CMR) is an excellent modality for the assessment of myocardial involvement. Studies have shown myocardial involvement in 25%-27% of patients. OBJECTIVES: To evaluate the prevalence and pattern of myocardial involvement in TA on CMR. We also evaluated any correlation between CMR changes and disease activity score (ITAS 2010 and ITAS-A) assessed at the time of CMR. METHODS: Patients classified as Takayasu arteritis according to Sharma et al. criteria were enrolled in the study. Demographic, clinical, and laboratory data were documented in the predesigned proforma. CMR was performed on a dedicated cardiac 3Tesla MR machine. Disease activity was recorded by ITAS2010 and ITAS-A. RESULTS: A total of 37 TA patients were included. Mean (±SD) age was 29±11 years. Female to male ratio was 3:1. Five patients (14%) had myocardial involvement on CMR. Two (2/5) had myocarditis and three (3/5) patients had features of ischaemic myocardial fibrosis. CONCLUSION: The myocardium is affected in TA, however the prevalence of subclinical myocardial involvement in our study was less (8% vs. 25%-27%) compared to the previous studies. Myocardial involvement trends towards early age of onset, less disease duration, lack of classical risk factors, and more with disease activity.

Systemic lupus erythematosus myocarditis after COVID-19 vaccination.

INTRODUCTION: Cases of acute myocarditis have been after administration of the BNT162b2 and Ad26.COV2.S vaccine. OBJECTIVE: Describe another possible mechanism of myocarditis after COVID-19 vaccination. CASE PRESENTATION: We describe the clinical case of a 72-year-old female with pleuritic chest pain one week after the third of the BNT162b2 mRNA vaccine. Serological tests for cardiotropic pathogens were negative, and autoimmunity screening was positive with anti-nuclear antibody (ANA) in 1:160 dilution, Anti-double-stranded DNA (anti-dsDNA), and anti-histone antibodies. 18F-fluoro-deoxy-glucose (FDG) positron emission tomography/computed tomography (PET/CT) showed a focal myocardial and pericardial inflammatory process in the cardiac apex. RESULTS AND DISCUSSION: Systemic lupus erythematosus (SLE) diagnosis was made with myocardial affection. As far as we know, this is the first report of a case of lupus myocarditis after the COVID-19 vaccine. CONCLUSION: Given the pathogenic rationales, the association between SLE and myocarditis should be considered.

Timing of cardiac magnetic resonance and diagnostic yield in patients with myocardial infarction with nonobstructive coronary arteries.

INTRODUCTION AND OBJECTIVES: The present study sought to establish the diagnostic yield of cardiovascular magnetic resonance (CMR) in a large cohort of patients admitted with myocardial infarction (MI) with nonobstructive coronary artery disease (MINOCA) based on the timing of referral to CMR. METHODS: Consecutive patients referred to CMR from January 2009 to February 2022 with a working diagnosis of MINOCA were retrospectively evaluated. Cine, T2-weighted, early, and late gadolinium-enhanced images were acquired and analyzed. The frequency of the underlying diagnosis and the association between timing of CMR and relative frequency of each diagnosis were assessed. RESULTS: We included 207 patients (median age 50 years, 60% men). Final diagnosis after CMR was achieved in 91% of the patients (myocarditis in 45%, MI in 20%, tako-tsubo cardiomyopathy in 19%, and other cardiomyopathies in 7%). The performance of CMR within 7 days of admission with MINOCA (median, 5 days; 117 patients) allowed a higher diagnostic yield compared with CMR performed later (median, 10 days; 88 patients) (96% vs 86%, P=.02). Although myocarditis was the most frequent diagnosis in both groups according to time to CMR, its frequency was higher among patients with a CMR performed within the first 7 days (53% vs 35%, P=.02). The frequency of other underlying diagnoses was not influenced by CMR timing. CONCLUSIONS: CMR led to an underlying diagnosis of MINOCA in 91% of patients and its diagnostic yield increased to 96% when CMR was performed within 7 days of admission. The most frequent diagnosis was myocarditis..

Endomyocardial biopsy-confirmed myocarditis and inflammatory cardiomyopathy: clinical profile and prognosis.

INTRODUCTION AND OBJECTIVES: Endomyocardial biopsy (EMB) is the only technique able to establish an etiological diagnosis of myocarditis or inflammatory cardiomyopathy (ICM). The aim of this study was to analyze the clinical profile, outcomes, and prognostic factors of patients with suspected myocarditis/ICM undergoing EMB. METHODS: We retrospectively analyzed the clinical characteristics, histological findings, and follow-up data of all patients with suspected myocarditis or ICM who underwent EMB between 1997 and 2019 in a Spanish tertiary hospital. The diagnostic yield was compared using the Dallas criteria vs immunohistochemical criteria (IHC). RESULTS: A total of 99 patients underwent EMB (67% male; mean age, 42±15 years; mean left ventricular ejection fraction [LVEF], 34%±14%). Myocarditis or ICM was confirmed in 28% with application of the Dallas criteria and in 54% with the IHC criteria (P <.01). Lymphocytic myocarditis was diagnosed in 47 patients, eosinophilic myocarditis in 6, sarcoidosis in 3, and giant cell myocarditis in 1 patient. After a median follow-up of 18 months, 23 patients (23%) required heart transplant (HTx), a left ventricular assist device (LVAD), and/or died. Among the patients with IHC-confirmed myocarditis, 21% required HTx/LVAD or died vs 7% of those without inflammation (P=.056). The factors associated with a worse prognosis were baseline LVEF ≤ 30%, left ventricular end-diastolic diameter ≥ 60mm, and NYHA III-IV, especially in the presence of inflammation. CONCLUSIONS: EMB allows an etiological diagnosis in more than half of patients with suspected myocarditis/ICM when IHC techniques are used. IHC-confirmed inflammation adds prognostic value and helps to identify patients with a higher probability of developing complications.

Pericardial and myocardial involvement after SARS-CoV-2 infection: a cross-sectional descriptive study in healthcare workers.

INTRODUCTION AND OBJECTIVES: The cardiac sequelae of SARS-CoV-2 infection are still poorly documented. We conducted a cross-sectional study in healthcare workers to report evidence of pericardial and myocardial involvement after SARS-CoV-2 infection. METHODS: We studied 139 healthcare workers with confirmed past SARS-CoV-2 infection. Participants underwent clinical assessment, electrocardiography, and laboratory tests, including immune cell profiling and cardiac magnetic resonance (CMR). Clinically suspected pericarditis was diagnosed when classic criteria were present and clinically suspected myocarditis was based on the combination of at least 2 CMR criteria. RESULTS: Median age was 52 (41-57) years, 71.9% were women, and 16.5% were previously hospitalized for COVID-19 pneumonia. On examination (10.4 [9.3-11.0] weeks after infection-like symptoms), participants showed hemodynamic stability. Chest pain, dyspnea or palpitations were present in 41.7% participants, electrocardiographic abnormalities in 49.6%, NT-proBNP elevation in 7.9%, troponin in 0.7%, and CMR abnormalities in 60.4%. A total of 30.9% participants met criteria for either pericarditis and/or myocarditis: isolated pericarditis was diagnosed in 5.8%, myopericarditis in 7.9%, and isolated myocarditis in 17.3%. Most participants (73.2%) showed altered immune cell counts in blood, particularly decreased eosinophil (27.3%; P<.001) and increased cytotoxic T cell numbers (17.3%; P <.001). Clinically suspected pericarditis was associated (P <.005) with particularly elevated cytotoxic T cells and decreased eosinophil counts, while participants diagnosed with clinically suspected myopericarditis or myocarditis had lower (P <.05) neutrophil counts, natural killer-cells, and plasma cells. CONCLUSIONS: Pericardial and myocardial involvement with clinical stability are frequent after SARS-CoV-2 infection and are associated with specific immune cell profiles.

Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries.

INTRODUCTION: The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS: On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS: The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS: In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.

Valproate, obesity and other causes of clozapine poor metabolism in the context of rapid titration may explain clozapine-induced myocarditis: A re-analysis of a Turkish case series.

INTRODUCTION: Clozapine-induced myocarditis or any clozapine-induced inflammation may be a hypersensitivity reaction due to titration that was too rapid for the patient's clozapine metabolism. Clozapine metabolism is influenced by ancestry, sex, smoking and the presence of confounders including obesity, infections, and inhibitors (e.g., valproate) causing the patient to behave as a clozapine poor metabolizer (PM). A published study in a Turkish hospital identified 1 case of clozapine-induced pancreatitis and hepatitis and 9 cases of clozapine-induced myocarditis. To explore the hypothesis that the 10 patients were clozapine PMs, their serum clozapine concentrations were investigated using concentration-to-dose (C/D) ratios and their titrations carefully reviewed. METHODS: Dividing the trough serum concentration by the dose produces the clozapine C/D ratio. The dose required to reach 350ng/ml was considered the minimum therapeutic dosage and was used to classify patients according to clozapine PM status. Titration speed was assessed. RESULTS: All 10 patients were possibly clozapine PMs (3 of them had as minimum therapeutic doses: 72, 82 or 83mg/day). Nine of the 10 patients may have behaved as clozapine PMs due to obesity and/or valproate co-prescription during titration. One also had an undiagnosed infection. Of the 10 patients, 9 had at least 1 of 3 factors: too-rapid titration in the first or second weeks, or a final dosage that was too high. CONCLUSIONS: Future studies using clozapine levels and considering the role of clozapine PM status should explore whether or not all cases of clozapine-induced inflammation could be explained by lack of individualized titration.

Return to exercise after COVID-19. Statement of the Mexican Society of Cardiology / Retorno al ejercicio después de COVID-19. Posicionamiento de la Sociedad Mexicana de Cardiología

The coronavirus disease 2019 (COVID-19) was declared a pandemic on March 11, 2020; one consequence has been the increase in sedentary lifestyle and reduction of sports activity. Exercise benefits the immune defense system especially in older adults; it is recommended to keep a distance of 1.5 meters between people, and if walking or jogging is carried out, the space must be up to 5 and 10 meters respectively. The reported cases are mostly mild up to 80% and can be critical in up to 4.7%; the risk factors are well known, hypertension, diabetes and previous heart disease. Severe or critical cases present as symptoms of acute respiratory distress syndrome, and in the case of cardiovascular disease, they mainly occur as myopericarditis, acute coronary syndromes, cardiogenic shock, thrombotic events, among others. Returning to exercise after recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is always recommended, however it will depend on the clinical picture what measures should be taken prior to its onset, and it is in moderate cases and especially in the severe ones where the evaluation and prescription prior to returning to exercise or sport should be guided by medical personnel experts in cardiopulmonary rehabilitation, especially in athletes.

La enfermedad por coronavirus 2019 (COVID-19) fue declarada pandemia el 11 de marzo de 2020; una consecuencia ha sido el incremento en el sedentarismo y la reducción de la actividad deportiva. El ejercicio beneficia el sistema inmunitario de defensa, especialmente en adultos mayores. Se recomienda guardar distancia de 1.5 metros entre personas, y si se realiza caminata o trote, el espacio debe ser de hasta 5 y 10 metros respectivamente. Los casos reportados son en su mayoría leves hasta en un 80%, y pueden ser críticos hasta en 4.7%; los factores de riesgo son bien conocidos: hipertensión, diabetes y enfermedad cardiaca previa. Los casos graves o críticos se presentan como cuadros de síndrome de distrés respiratorio agudo y ante afección cardiovascular cursan principalmente como miopericarditis, síndromes coronarios agudos, choque cardiogénico y eventos trombóticos, entre otros. El ejercicio después de la recuperación de infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2) siempre está recomendado, sin embargo, dependerá del cuadro clínico qué medidas se deben tomar previo a su inicio, y es en casos moderados y especialmente en los graves donde la evaluación y prescripción previa al retorno al ejercicio o deporte debe ser guiada por personal médico experto en rehabilitación cardiopulmonar, en especial en deportistas.

[Myocarditis and in situ thrombosis in the right ventricle in a COVID-19 patient]. / Miocarditis y trombosis in situ en ventrículo derecho en paciente COVID-19.

Although SARS-CoV-2 mainly affects the respiratory system, its impact on other systems is becoming increasingly evident. Cardiovascular involvement is highly significant in the form of acute myocardial damage (AMD) and thromboembolic complications due to the hypercoagulable state produced by this infection. This clinical case presents the coexistence of several cardiovascular complications in a young patient, with no previous disease and recent COVID-19 infection. It also highlights the need for screening for cardiovascular complications by imaging techniques due to the increase in their incidence.

Cardiovascular disorders in hospitalized patients with dengue infection. / Manifestaciones cardiovasculares en pacientes hospitalizados con dengue.

INTRODUCTION: Cardiac complications in dengue patients are not uncommon and are not diagnosed, since they are usually mild and self-limiting. OBJECTIVES: To characterize the cardiovascular manifestations in hospitalized patients with dengue infection. METHODS: We conducted an observational, analytical, longitudinal, prospective epidemiological study, which included 427 patients treated at Manuel Fajardo Clinical-Surgical Teaching Hospital with diagnosis of dengue infection since April 2017 to April 2018. RESULTS: Cardiovascular manifestations (19.7%), mainly heart rate disorders (sinus bradycardia [13.8%], atrial [4.9%] and ventricular [4.0%] extrasystoles) were frequent in dengue infection patients. Pericarditis and myocarditis were diagnosed in 1.6% and 0.2% respectively. These disorders were self-limiting in 83.3% of cases and occurred in the first days of the onset of fever in 75.0%. Advanced age (OR=1.70), male sex (OR=1.94), decreased platelet count (OR=1.13) and dengue with warning signs (OR=3.29) were related to a higher probability of presenting cardiovascular disorders in the course of a dengue infection. CONCLUSIONS: Cardiovascular manifestations in dengue patients are frequent, and are related to advanced age, male sex, as well as severe forms of the disease.

Additional value of hybrid PET/MR imaging versus MR or PET performed separately to assess cardiovascular disease.

INTRODUCTION AND OBJECTIVES: Hybrid positron emission tomography (PET) and magnetic resonance (MR) imaging is an emerging technology in the diagnosis of cardiovascular disease; however, there have been no reports of its use in the national clinical setting. Our objective was to evaluate the additional value of integrated PET/MR systems compared with MR and PET performed separately in this setting. METHODS: We prospectively included 49 patients, 30 to assess myocardial viability (coronary group) and 19 to assess inflammatory, infectious, and tumoral diseases (noncoronary heart disease group). All patients underwent cardiac 18F-fluorodeoxyglucose PET/MR. PET/MR studies included attenuation correction sequences, followed by simultaneous cardiac PET and cardiac MR acquisition, with protocols adapted to the clinical indication (cine, tissue characterization and/or late enhancement imaging). RESULTS: Most (87.8%) PET/MR studies were initially interpretable. Use of PET/MR improved diagnosis vs PET or MR performed separately in 42.1% of coronary cases and 88.9% of noncoronary cases. PET/MR enabled reclassification of 87.5% of coronary cases initially classified as showing inconclusive results on MR or PET and 70% of noncoronary cases. CONCLUSIONS: In our series, multimodality PET/MR technology provided additional diagnostic value in some patients with cardiovascular disease compared with MR and PET performed separately, especially in cases of noncoronary heart disease and in those with inconclusive results on MR or PET. In our experience, the main benefits of PET/MR include the possibility of simultaneous acquisition, the in vivo integration of anatomical/functional/metabolic aspects, and the interaction of different experts in imaging modalities.

Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries.

INTRODUCTION: The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS: On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS: The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS: In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.

Scleroderma Renal Crisis: A Reversible Cause of Left Ventricular Dysfunction.

We report a case of acute left ventricular dysfunction due to myocarditis, in the setting of a scleroderma renal crisis. The case is particularly intriguing for the favorable outcome of both symptoms and heart function following immunosuppressive therapy. We also highlight the changes observed over time with image techniques as well as in electrocardiograms.

Manifestaciones extrapulmonares de la infección por SARS-CoV-2.

The disease caused by a new coronavirus, which started in 2019, was named COVID-19 and declared a pandemic on March 11, 2020 by the World Health Organization. Although it is true that the first reports emphasized the respiratory manifestations of this disease as an initial clinical presentation, little by little cases with different initial manifestations began to appear, involving other systems. In cases where central nervous system involvement was identified, the most frequent findings were dizziness, headache, and alteration of alertness. Regarding the cardiovascular system, elevation of cardiac biomarkers and myocarditis are one of the most frequent findings. The main gastrointestinal symptoms described so far are: anorexia, nausea, vomiting, diarrhea, abdominal pain and/or discomfort. Venous thromboembolism is a frequent complication and a public health problem. Skin manifestations remain a field of investigation. Maculopapular rashes, reticular livedo, acral gangrene, among others, have been identified. Health personnel must be updated on new clinical findings and the forms of presentation of this partially known disease, which will make it possible to make more accurate and timely diagnoses, thus impacting the prognosis of these patients.

La enfermedad causada por un nuevo coronavirus, que inició en 2019, fue denominada COVID-19 y declarada pandemia el 11 de marzo de 2020 por la Organización Mundial de la Salud. Si bien es cierto que los primeros reportes enfatizaron las manifestaciones respiratorias de esta enfermedad como presentación clínica inicial, poco a poco empezaron a aparecer casos con manifestaciones iniciales distintas, involucrando otros sistemas. En los casos en los que se identificó afectación del sistema nervioso central, los hallazgos más frecuentes fueron mareo, cefalea y alteración del estado de alerta. Respecto al sistema cardiovascular, la elevación de biomarcadores cardiacos y la miocarditis son unos de los hallazgos más frecuentes. Los principales síntomas gastrointestinales descritos hasta el momento son anorexia, náuseas, vómitos, diarrea y dolor o disconfort abdominal. La tromboembolia venosa es una complicación frecuente y un problema de salud pública. Las manifestaciones cutáneas siguen siendo un campo de investigación. Se han identificado exantemas maculopapulares, livedo reticular y gangrena acral, entre otros. El personal sanitario debe estar actualizado sobre los nuevos hallazgos clínicos y las formas de presentación de esta enfermedad solo parcialmente conocida, lo que permitirá hacer diagnósticos más precisos y oportunos, y así impactar en el pronóstico de estos enfermos.

Miocarditis inducida por Clozapina: Revisión y protocolo de Screening

Clozapina, el gold standard en esquizofrenia refractaria, presenta algunos efectos adversos que ocasionalmente pueden ser graves. Entre ellos, la miocarditis precoz es un efecto cardiovascular severo poco frecuente que puede aparecer en las primeras 4-6 semanas. Las cifras de incidencia oscilan entre el 0,015-0.188% en el mundo, siendo más altas en Australia. La etiología es desconocida, postulándose hipersensibilidad mediada por Ig E; hipereosinofilia y hiperadrenergia. Múltiples investigaciones avalan a la ecocardiografía como una de las técnicas más útiles para el diagnóstico. La biopsia endomiocárdica es definitoria pero no viable. Existen, asimismo, criterios de RNM indicativos de inflamación miocárdica. Para facilitar el diagnóstico, se han propuesto criterios clínicos y analíticos de screening (hemograma, ECG, CK, PCR, troponinas). En caso de sospecha de miocarditis, el cese de clozapina y el tratamiento de soporte es la actitud a seguir, habitualmente con buenos resultados.

Although Clozapine is the gold standard treatment in resistant-schizophrenia, severe or even life-threatening adverse effects must be taked into account. Early myocarditis, a severe but unusual cardiovascular effect, can appear in the first 4-6 weeks of initiation. Incidence rates of myocarditis are about 0,015-0,188% around the world, being more elevated in Australia. Aethiology is unknown, suggesting Ig E mediated hipersensibility, hiperaeosinophilia and hiperadrenergy. Echocardiography seems to be one of the most helpful tools for diagnosing myocarditis. Endomyocardial biopsy is definitive, but not usually available. A role for cardiac magnetic resonance imaging (MRI) also has been proposed (findings of inflammation). In order to make an early diagnosis, several screening-criteria, considering clinical and laboratory ones, have been proposed: aeosinophylia, creatininkinase, C Reactive Proteine, troponin, and EKG. If we suspected clozapine-induced myocarditis, the drug must be removed and support medical treatment must be indicated.