Diphtheria-Associated Myocarditis: Clinical Profiles and Mortality Trends in a Tertiary Care Hospital in Pakistan.

BACKGROUND: Corynebacterium diphtheriae infection, causing diphtheria, is a public health concern, particularly in developing nations like Pakistan. Despite immunization efforts, recent outbreaks since 2022 have emphasized the continuing threat. This study focuses on describing the clinical characteristics of children with diphtheria-induced myocarditis and exploring the association between early cardiac abnormalities, future fatality rates, and contributing factors. METHODS: A one-year cross-sectional study was undertaken at Lady Reading Hospital MTI Peshawar, encompassing 73 pediatric patients diagnosed with diphtheria-associated myocarditis. Data, including demographic characteristics, cardiac enzymes, and serial ECG and echocardiography data, were gathered from the health management information system (HMIS). Institutional Ethical Committee approval was obtained, and informed consent was waived due to its retrospective nature. RESULTS: Gender distribution within the study was balanced, with 35 males (47.9%) and 38 females (52.1%). ECG data revealed various prevalence rates: 27.4% for rhythm abnormalities, 20% for conduction abnormalities, 6.8% for ischemia alterations, and 20.5% for normal findings. Treatment measures included anti-diphtheria serum (ADS) in 87.7% and temporary pacemaker placement (TPM) in 13.7% of patients. Echo findings indicated a variety of cardiac dysfunctions: 53.4% with no dysfunction, 9.6% mild malfunction, 6.8% with moderate dysfunction, and 30.1% with severe dysfunction. The categorization of creatine kinase (CK), lactate dehydrogenase (LDH), and troponin I (Trop I) gave insights into the biochemical aspects. CONCLUSION: This study gives a full insight into the clinical symptoms of diphtheria-induced myocarditis in children. The findings can help establish a foundation for ongoing study into potential gender-related trends in clinical outcomes, contributing to improved care and preventative methods.

Diphtheria's Dual Threat: Amplifying Awareness of Cardiac Complications for Enhanced Intervention.

Even though immunization can prevent illness, diphtheria, which is caused by toxic strains of Corynebacterium diphtheriae, remains a serious public health risk. Although the worldwide incidence has declined, it still poses a serious hazard in developing countries, such as Pakistan, where new data suggest an increase in cases. A significant proportion of patients with respiratory diphtheria experience cardiac complications, specifically myocarditis, which carries a high death risk of 50% to 75%. The diphtheria toxin's affinity for cardiac tissues is the cause of these consequences, which include arrhythmias and myocardial dysfunction. Recent studies from Lady Reading Hospital in Peshawar show the seriousness of the situation, with 73 patients presenting with cardiac complications in just one year, resulting in a devastating fatality rate despite early management. This highlights the pressing need for increased awareness and all-encompassing immunization campaigns, particularly for children who have received insufficient vaccinations. Timely vaccination and booster doses are critical for reducing myocarditis-related mortality, mandating prioritizing immunization efforts to defend susceptible populations globally.

Clinical Presentation, Diagnosis, Treatment, and Outcomes of Myocarditis in Children: A Tertiary Care Hospital Experience.

Background Clinical presentation, diagnosis, and treatment of myocarditis in children can be highly challenging, and results can vary greatly. Research on the precise processes of myocardial injury, including the effects of viral infections and newly identified variables like COVID-19, is still underway. Though treatment approaches, such as immunosuppressive therapy, are still debatable, diagnostic methods such as cardiac MRI and biomarkers show promise in improving diagnostic accuracy. The purpose of this study is to describe the spectrum of pediatric acute myocarditis, assess existing therapy approaches, and develop regional guidelines based on the experience of a tertiary care institution.  Methods Children diagnosed with acute myocarditis over a six-month period were included in this retrospective and descriptive hospital-based study. Data on demographics, clinical presentations, diagnostic tests, treatments, and results were gathered and examined. Descriptive statistics, non-parametric tests for categorical variables, and Spearman's correlation tests for continuous data were used in the statistical analysis, with a significance level of p < 0.05.  Results Of the 99 patients included, the mean age was 2.37 years, with males making up the majority (n = 54, 54.55%). Clinical symptoms typically included shortness of breath (n = 998, 99.0%), vomiting (n = 63, 63.6%), and chest pain (n = 6, 6.1%). High levels of troponin I (n = 70, 70.7%), cardiomegaly on a chest X-ray (n = 97, 97.0%), and different degrees of ventricular dysfunction were found in the laboratory and in imaging studies. Methylprednisolone (n = 84, 84.8%) and IV immunoglobulin (n = 54, 54.5%) were the most often used treatment modalities, and there were no appreciable differences in the two treatment groups' outcomes. A weak negative association (Spearman's rho = -0.211, p = 0.036) was found in the correlation study between the administration of methylprednisolone and length of stay (LOS), indicating possible benefits in terms of shortening hospital stays.  Conclusion This research offers a significant understanding of the clinical manifestation, treatment, and complications of acute myocarditis in children. Methylprednisolone administration seems to be linked to a shorter length of stay (LOS), despite disagreements over treatment approaches. To confirm these results and provide guidance for evidence-based management guidelines for pediatric myocarditis in our setup, more studies are necessary.

Pattern of Vascular Anomalies Associated With Sinus Venosus Atrial Septal Defect.

Objective To evaluate children with sinus venosus atrial septal defect (SV-ASD) for associated vascular anomalies. Methodology A total of 72 children with sinus venosus atrial septal defect with partial anomalous pulmonary venous return who presented to pediatric cardiology unit, Lady Reading Hospital Peshawar, from January 2019 till June 2021 were included in this cross-sectional study. Diagnosis of sinus venosus atrial septal defect was confirmed through two-dimensional (2D) and Doppler echocardiography performed by a pediatric cardiologist. Cardiac CT angiography was performed and assessed by a pediatric cardiac interventionist and radiologist. Patients were managed according to standard protocols and guidelines. The data were entered and analyzed with Statistical Package for the Social Sciences (SPSS) version 20. Percentages were used to express frequencies. Results Mean age was 8.3 ± 2.7 years (interquartile range (IQR): two months to 18 years). There were 37 (51.4%) male and 35 (48.6%) female patients. Out of 72 patients, 64 (88.8%) patients had superior sinus venosus atrial septal defect, while inferior sinus venosus atrial septal defect was found in eight (11.1%) patients. In six (8.3%) patients, associated secundum atrial septal defect was identified. Bilateral superior vena cava was found in seven (9.7%) patients. Left aortic arch was seen in 70 (97.2%) patients, whereas two (2.7%) patients had right aortic arch. Conclusion Sinus venosus ASD is a rare type of atrial septal defect which is also associated with both pulmonary and systemic vascular anomalies. Diagnosing these vascular anomalies is of paramount importance before any corrective intervention can be done. Recognizing the pattern of these anomalies should be known to every interventional cardiologist, radiologist, and cardiac surgeon. Echocardiography alone is not a good tool to assess these extracardiac structures. Imaging modalities like CT angiography and MRI have refined our preoperative workup which is essential for the ultimate outcome of the corrective intervention.

The Outcome of Trans-catheter Closure of Patent Ductus Arteriosus: A Single-Center Experience.

Objective The objective is to share our experience of trans-catheter device closure of patent ductus arteriosus (PDA) and review its efficacy and immediate complications. Methodology This cross-sectional observational study was done in the Department of Pediatric cardiology, Lady Reading Hospital, Peshawar from January 2020 to December 2020. A total of 51 patients with isolated PDA, who underwent PDA device closure, were enlisted in this study through consecutive sampling methods, irrespective of their age and gender. Data of the patients were collected on preformed pro forma. Data was entered in SPSS 20 (SPSS Inc., Chicago, IL, USA). Descriptive statistics like mean ± SD for numerical data (age, weight, and hospital stay), while frequency and percentage for categorical variables (Device type, complication, hospital stay, and type of anesthesia given) were calculated. Results Among total 51 patients (33 [64.7%] females and 18 [35.3%] males) with mean age 8.19 ± 6.96 years underwent attempted trans-catheter PDA device closure. In all cases PDA was successfully occluded with appropriate size devices. General anesthesia was given in 38 (74.5%) patients. Complications occurred in only four (7.8%) patients in the form of hemolysis followed by acute kidney injury in one patient, another had device embolization to descending aorta, which was retrieved in cath lab, one had device embolization to the right pulmonary artery, which was retrieved in cath lab and one had mild left ventricular systolic dysfunction. The mean duration of hospital stay was 22.0 ± 10.2 h. Conclusion Trans-catheter PDA device closure is a safe procedure with a high success rate and little morbidity.

Emergency Department Presentation and Outcome of Children With Cyanotic Congenital Heart Diseases.

Objective This study aimed to assess the outcome and see the spectrum of presenting symptoms of children with cyanotic congenital heart diseases (CHDs) admitted through the emergency department in Lady Reading Hospital (LRH) in Peshawar, Pakistan. Materials and methods This cross-sectional study included 104 children with cyanotic CHD admitted through the emergency department in the pediatric cardiology unit of LRH from February 2019 to January 2020. Diagnosis of cyanotic CHD was confirmed through two-dimensional echocardiography. Patients were treated according to standard protocols for their presenting symptoms. The data were analyzed using Statistical Package for the Social Sciences (SPSS), version 20.0 (IBM Corp., Armonk, NY) and frequencies were expressed as percentages. Results The study included 65 male cases (62.5%) and 39 female cases (37.5%), and participant ages ranged from 10 days to 15 years (mean, 2.7 ± 3.4 years). Of 104 patients, 70 presented with cyanotic spells (84.5%), 53 with fever (10.7%), 28 with respiratory distress (26.5%), 11 with loose stools (10.5%), 10 with hemiplegia (9.6%), and eight with seizures (7.6%). Pneumonia was a precipitating factor in 13 patients (12.5%), infective endocarditis in 12 patients (11%), gastroenteritis in 11 (11%), brain abscess and cerebrovascular accidents in seven patients each (6% each), meningitis in six patients (6%), and tuberculous pericardial effusion in one patient (<1%). The primary CHD was tetralogy of Fallot (TOF) in 52 patients, tricuspid atresia in 14 patients, pulmonary atresia in 13 patients, double outlet right ventricle in 10 patients, transposition of great arteries (TGA) in seven patients, and total anomalous pulmonary venous return (TAPVR), truncus arteriosus, congenitally corrected TGA, and critical pulmonary stenosis in two patients each. Twenty-six patients received treatment of the acute problem and instructions for follow-up monitoring. Twelve patients died during their hospital stay, and three left against medical advice. Fifteen patients received patent ductus arteriosus stenting, and six received right ventricular outflow tract stenting. One patient received a Blalock-Taussig (BT) shunt stent, and one received a left pulmonary artery stent. Two patients received a balloon pulmonary valvotomy, and one received pericardial effusion drainage. Eleven patients received surgical correction of TOF, 11 received surgical correction for BT shunt, four received surgical correction for brain abscess drainage, and two received TAPVR repair. Conclusion TOF was the most common cyanotic heart disease in our study. Cyanotic spells or increased cyanosis was the most common presenting concern. Cyanotic CHDs present with variable extracardiac signs and symptoms in emergencies. Appropriate assessment, immediate management of the acute problem, and timely intervention or surgical management result in good outcomes.

Outcome Of Balloon Valvuloplasty In Children With Pulmonary Stenosis - Single Center Experience.

BACKGROUND: Pulmonary valve stenosis (PS) is common congenital heart disease in children and patient can present with cyanosis, chest pain, dyspnea and failure with severe form. The objective of this study was to enlighten the short outcome of balloon pulmonary valvuloplasty in children with severe pulmonary stenosis. METHODS: This cross sectional observational study was done in paediatric cardiology department of Lady Reading Hosptial, Peshawer form June 2019 to December 2020 over 1.5 years. Children aged 6 months to 16 years of either sex diagnosed as case of severe stenosis with doming pulmonary valve and having symptoms of chest pain and dysnea on exeration and pregradient pressure of 64 mm Hg or more on echocardiography were included. Patients were interviened with ballon-valvuloplasty. Outcome was taken as discharge from hospital with complications after procedure if any. Patients were followed up for 3 months. Data including age, sex, pre cath echocardiography, cath pulmonary valve annulus, post ballooning pulmonary valve (PV) gradient, PV gradient on echocardiography after intervention and follow up gradient on echocardiography at three months was documented. Data was analyzed by SPSS 20. Chi square test and paired T - Test was applied where required. Results were taken as significant with p value <0.05. RESULTS: There were 51 patients, 35 (68.6%) male and 16 (31.4%) female. Mean age was 8.35±4.93 years. Mean pre cath gradient across the pulmonary valve on echocardiography was 109.14±31.44 mm Hg. Post intervention mean pressure gradient across PV was 32.41±11.49 mm Hg. Pulmonary valve annulus on echocardiography before intervention ranged from 7 to 25 mm with mean of 14.67±3.79 mm. There was no complication in majority (82.4%) of patients. Mild PR was in 5 (9.8%) patients. There was significant relationship between pre and post intervention pressure gradient across PV valve with p value of <0.001. CONCLUSIONS: Balloon pulmonary valvuloplasty in one of the safest intervention for PS in children with few complications.

Echomorphology of cardiomyopathy: review of 217 cases from 1999 to 2010.

OBJECTIVE: To study echocardiogram features of different types of cardiomyopathy presenting over a 12 year period at a single centre in Peshawar. METHODS: The series comprised a retrospective review of 13,788 consecutive echocardiograms carried out at the Muhammadi Hospital International Medical Research Centre, Hayatabad, Peshawar, from January 1999 to December 2010. Patients were split into two: Group I with paeditaric and adolescent cases (0-18 years) and Group II with adults (> 18 years). In the adult group, women with peripartum cardiomyopathy were subdivided into two groups of 18-30 years and 30 to 44 years. Standard Echo B and M modes and Doppler parameters were recorded to ascertain the diagnoses of common primary and secondary cardiomyopathies. Patients with myocarditis with chambers' dilatation and global dysfunction, and cardiopathy associated with major cardiovascular diseases were excluded. SPSS 14 was used for statistical analysis. RESULTS: Cardiomyopathy was diagnosed in 217 (1.57%) cases. There were 144 (66%) cases of dilated cardiomyopathy with a mean age of 13 +/- 14.8 years; 17 (8%) cases of hypertrophic cardiomyopathy with a mean age of 12 +/- 11.5 years; and 7 (3%) cases of restrictve cardiomyopathy with a mean age of 31 +/- 7.8 years. Primary cardiac amyloidosis was confirmed in 9 (4%) cases, and peripartum cardiomyopahty in 25 (11%) females. Rare subtypes were found in 15 (7%) cases. CONCLUSION: DCM was the most frequently diagnosed subtype of cardiomyopathy followed by HCM in both the adult and paediatric age groups.

Progeria syndrome with cardiac complications.

A case report of 6-year-old boy with progeria syndrome, with marked cardiac complications is presented. The boy had cardiorespiratory failure. Discoloured purpuric skin patches, alopecia, prominent forehead, protuberant eyes, flattened nasal cartilage, malformed mandible, hypodentition, and deformed rigid fingers and toes were observed on examination. The boy was unable to speak. A sclerotic systolic murmur was audible over the mitral and aortic areas. Chest x-rays showed cardiac enlargement and the electrocardiogram (ECG) showed giant peaked P waves (right atrial hypertrophy) and right ventricular hypertrophy. Atherosclerotic dilated ascending aorta, thickened sclerotic aortic, mitral, and tricuspid valves with increased echo texture, left and right atrial and right ventricular dilatation, reduced left ventricular cavity, and thickened speckled atrial and ventricular septa were observed on echocardiography.