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1.
Int J Legal Med ; 135(6): 2335-2345, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34591186

RESUMO

Thorough postmortem investigations of fatalities following vaccination with coronavirus disease 2019 (COVID-19) vaccines are of great social significance. From 11.03.2021 to 09.06.2021, postmortem investigations of 18 deceased persons who recently received a vaccination against COVID-19 were performed. Vaxzevria was vaccinated in nine, Comirnaty in five, Spikevax in three, and Janssen in one person. In all cases, full autopsies, histopathological examinations, and virological analyses for the severe acute respiratory syndrome coronavirus 2 were carried out. Depending on the case, additional laboratory tests (anaphylaxis diagnostics, VITT [vaccine-induced immune thrombotic thrombocytopenia] diagnostics, glucose metabolism diagnostics) and neuropathological examinations were conducted. In 13 deceased, the cause of death was attributed to preexisting diseases while postmortem investigations did not indicate a causal relationship to the vaccination. In one case after vaccination with Comirnaty, myocarditis was found to be the cause of death. A causal relationship to vaccination was considered possible, but could not be proven beyond doubt. VITT was found in three deceased persons following vaccination with Vaxzevria and one deceased following vaccination with Janssen. Of those four cases with VITT, only one was diagnosed before death. The synopsis of the anamnestic data, the autopsy results, laboratory diagnostic examinations, and histopathological and neuropathological examinations revealed that VITT was the very likely cause of death in only two of the four cases. In the other two cases, no neuropathological correlate of VITT explaining death was found, while possible causes of death emerged that were not necessarily attributable to VITT. The results of our study demonstrate the necessity of postmortem investigations on all fatalities following vaccination with COVID-19 vaccines. In order to identify a possible causal relationship between vaccination and death, in most cases an autopsy and histopathological examinations have to be combined with additional investigations, such as laboratory tests and neuropathological examinations.


Assuntos
Vacinas contra COVID-19 , Medicina Legal , Vacinação/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anafilaxia/mortalidade , Autopsia , Causalidade , Causas de Morte , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Miocardite/mortalidade , Púrpura Trombocitopênica Idiopática/mortalidade
2.
Cardiovasc Pathol ; 54: 107361, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34174415

RESUMO

COVID-19 has a significant effect upon the cardiovascular system. While a number of different cardiovascular histopathologies have been described at post-mortem examination, the incidence of typical viral myocarditis in COVID-19 positive patients appears very low [1-3]. In this study, we further characterize and quantify the inflammatory cell infiltrate in a COVID-19 study cohort and compare the findings to both an age and disease matched control cohort and a cohort of patients diagnosed with typical inflammatory myocarditis. All study and control cohorts had 1 or more of the comorbidities most commonly associated with severe disease (hypertension, type II diabetes, obesity, or known cardiovascular disease). The results demonstrate a skewed distribution of the number of CD68+ cells in COVID-19 hearts, with upper quantiles showing a significant increase as compared to both matched control hearts, and those with myocarditis. In contrast, hearts from typical inflammatory myocarditis contained increased numbers of CD4+, and CD8+ cells compared to both COVID-19 and control cohorts. In conclusion, the presence of an increased number of CD68+ cells suggests that COVID-19 may incite a form of myocarditis different from typical viral myocarditis, and associated with diffusely infiltrative cells of monocytes/macrophage lineage.


Assuntos
Antígenos CD/análise , Antígenos de Diferenciação Mielomonocítica/análise , COVID-19/imunologia , Macrófagos/imunologia , Miocardite/imunologia , Miocárdio/imunologia , Adulto , Idoso , Autopsia , Biomarcadores/análise , COVID-19/mortalidade , COVID-19/patologia , COVID-19/virologia , Estudos de Casos e Controles , Feminino , Interações Hospedeiro-Patógeno , Humanos , Imuno-Histoquímica , Macrófagos/virologia , Masculino , Pessoa de Meia-Idade , Miocardite/mortalidade , Miocardite/patologia , Miocardite/virologia , Miocárdio/patologia , SARS-CoV-2/imunologia , SARS-CoV-2/patogenicidade
3.
PLoS One ; 16(2): e0246301, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33539453

RESUMO

BACKGROUND: In 2017, a diphtheria outbreak occurred in several provinces in Indonesia. The aim of this study was to identify predictors of mortality outcome of pediatric patients with clinical diphtheria. METHODS: A retrospective cohort study was conducted using patient medical records at five referral hospitals in the Province of Jakarta and one in Tangerang District, Banten Province during January 2017 to 31 August 2018. All children in the age group of 1-18 years old discharged with diagnosis of clinical diphtheria formed the study group. All anonymized patient data were evaluated for demographic issues, clinical features, immunization status, complication, laboratory profiles and outcome. RESULTS: A total of 283 patients with clinical diphtheria were included in the study group with case fatality rate of 3.5%. All mortal patients had the complication of myocarditis. Regression analyses revealed factors for predicting mortality. Incomplete primary diphtheria toxoid immunization, stridor, bull neck, leukocytosis ≥15 x109 cells/L and thrombocytopenia ≤150 x109 cells/L in each combination for 2 predictors modeling were correlated with death. CONCLUSIONS: We report key predictors of mortality in pediatric patients with clinical diphtheria. The presence of these features when admitted to the hospital must be taken into account, because they can lead to fatal outcome.


Assuntos
Difteria/epidemiologia , Difteria/mortalidade , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Difteria/complicações , Surtos de Doenças/prevenção & controle , Feminino , Hospitalização , Humanos , Imunização , Indonésia/epidemiologia , Lactente , Masculino , Registros Médicos , Miocardite/epidemiologia , Miocardite/mortalidade , Análise de Regressão , Estudos Retrospectivos , Vacinação
5.
Pediatr Cardiol ; 42(1): 59-71, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33025028

RESUMO

Racially disparate health outcomes exist for a multitude of populations and illnesses. It is unknown how race and ethnicity impact mortality for children with cardiomyopathy or myocarditis. This retrospective cross-sectional study employed the Kids' Inpatient Database to analyze 34,617 hospital admissions for patients ≤ 18 years old with cardiomyopathy, myocarditis, or both, without concomitant congenital heart disease. Multivariate logistic regression models investigated the impact of race/ethnicity on in-hospital mortality adjusting for age, calendar year, sex, insurance type, diagnostic category, treatment at a pediatric hospital, and non-cardiac organ dysfunction. African American race and Hispanic ethnicity were independent risk factors for mortality (African American: odds ratio (OR) 1.25, 95% confidence interval (CI) 1.01-1.53 and Hispanic: OR 1.29, 95% CI 1.03-1.60). African American race was also found to be significantly associated with the use of extracorporeal membrane oxygenation (ECMO), mortality while on ECMO, and cardiac arrest. Adjusting the regression model for ECMO and arrest attenuated the impact of African American race on mortality, suggesting that these variables may indeed play a role in explaining the impact of race on mortality for African American patients with myocardial disease. Hispanic ethnicity remained associated with higher risk of mortality despite controlling for all mechanical circulatory support and transplant (OR 1.30, 95% CI 1.04-1.63). Children of racial and ethnic minorities hospitalized with cardiomyopathy or myocarditis are more likely to die than their white counterparts, a trend that may be due at least in part to in-hospital differences in care or response to therapy.


Assuntos
Cardiomiopatias/mortalidade , Disparidades em Assistência à Saúde/etnologia , Mortalidade Hospitalar/etnologia , Miocardite/mortalidade , Adolescente , Afro-Americanos/estatística & dados numéricos , Cardiomiopatias/etnologia , Criança , Pré-Escolar , Estudos Transversais , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Parada Cardíaca/etnologia , Parada Cardíaca/mortalidade , Cardiopatias Congênitas/etnologia , Cardiopatias Congênitas/mortalidade , Hispano-Americanos/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais Pediátricos , Humanos , Lactente , Modelos Logísticos , Masculino , Miocardite/etnologia , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
6.
Crit Pathw Cardiol ; 20(1): 44-52, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32467423

RESUMO

Due to the lack of prospective, randomized, controlled clinical studies on inflammation and cardiovascular involvement, the exact mechanism of cardiac injury among patients with Coronavirus Disease 2019 (COVID-19) still remains uncertain. It was demonstrated that there is a high and significantly positive linear correlation between troponin T and plasma high-sensitivity C-reactive protein levels, biomarkers of cardiac injury and systemic inflammation, respectively. Cardiac injury and inflammation is a relatively common association among patients hospitalized with COVID-19, and it is related to higher risk of in-hospital mortality. In our literature search, we identified several potential mechanisms of myocardial tissue damage, namely, coronavirus-associated acute myocarditis, angiotensin-converting enzyme 2 receptor binding affinity to the virus Spike protein, increased cytokine secretion, and hypoxia-induced cardiac myocyte apoptosis. Elucidation of the disease pathogenesis and prospective histopathological studies are crucial for future proper treatment in case of renewed outbreaks. Of interest is that with hundred of thousands of bodies available for autopsy studies, no prospective investigation has been reported so far. Strong efforts and continued research of the cardiovascular complications and identification of risk factors for poor prognosis in COVID-19 are steadily needed. The high morbidity and mortality of COVID-19, its monumental economic burden and social impact, the despair of a new pandemic outbreak, and the thread of potential utilization of novel severe acute respiratory syndrome coronavirus 2 as biologic weapons make it a preponderant necessity to better comprehend the therapeutic management of this lethal disease. Emerging as an acute infectious disease, COVID-19 may become a chronic epidemic because of genetic recombination. Therefore, we should be ready for the reemergence of COVID-19 or other coronaviruses.


Assuntos
Arritmias Cardíacas/virologia , COVID-19/complicações , Miocardite/sangue , Miocardite/virologia , SARS-CoV-2/patogenicidade , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , COVID-19/sangue , COVID-19/mortalidade , Citocinas/sangue , Hospitalização , Humanos , Miocardite/mortalidade , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Troponina T/sangue
7.
Arthritis Rheumatol ; 73(5): 866-874, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33258544

RESUMO

OBJECTIVE: To estimate the incidence of immune checkpoint inhibitor-related myositis (ICI-myositis) in cancer patients receiving ICIs, and to report associated clinical manifestations, patterns of care, and outcomes. METHODS: We identified a retrospective cohort of patients receiving ICIs between 2016 and 2019 seen at the University of Texas MD Anderson Cancer Center. Cases of ICI-myositis were identified using International Classification of Disease codes and confirmed by reviewing medical records and pathology, as available. RESULTS: A total of 9,088 patients received an ICI. Thirty-six patients (0.40%) were identified as having ICI-myositis: 17 patients (47%) with ICI-myositis alone and 19 (53%) with overlap manifestations (5 patients with myocarditis, 5 with myasthenia gravis, and 9 with both). The incidence of ICI-myositis was 0.31% in those receiving ICI monotherapy and 0.94% in those receiving combination ICI therapy (relative risk 3.1 [95% confidence interval 1.5-6.1]). Twenty-five patients (69%) received ≥1 treatment in addition to glucocorticoids: plasmapheresis in 17 patients (47%), intravenous immunoglobulin in 12 (33%), and biologics in 11 (31%). Patients with overlap conditions had worse outcomes than those with myositis alone, and 79% of them developed respiratory failure. Eight patients died as a result of ICI-myositis, and all had overlap syndrome with myasthenia gravis or myocarditis (P < 0.05); 75% of these patients had a concomitant infection. CONCLUSION: ICI-myositis is a rare but severe adverse event. More than half of the patients presented with overlap manifestations and had deleterious outcomes, including respiratory failure and death. None of the patients with ICI-myositis alone died as a result of adverse events. Optimal treatment strategies have yet to be determined.


Assuntos
Inibidores de Checkpoint Imunológico/efeitos adversos , Miastenia Gravis/induzido quimicamente , Miocardite/induzido quimicamente , Miosite/induzido quimicamente , Neoplasias/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Infecções/epidemiologia , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/epidemiologia , Miastenia Gravis/mortalidade , Miocardite/epidemiologia , Miocardite/mortalidade , Miosite/epidemiologia , Miosite/mortalidade , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Estudos Retrospectivos
8.
Cardiovasc Pathol ; 50: 107300, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33132119

RESUMO

The COVID-19 pandemic, the result of severe acute respiratory syndrome (SARS)-CoV-2, is a major cause of worldwide mortality with a significant cardiovascular component. While a number of different cardiovascular histopathologies have been reported at postmortem examination, their incidence is unknown, due to limited numbers of cases in any given study. A literature review was performed identifying 277 autopsied hearts across 22 separate publications of COVID-19 positive patients. The median age of the autopsy cohort was 75 and 97.6% had one or more comorbidities. Initial review of the data indicate that myocarditis was present in 20 hearts (7.2%); however, closer examination of additional reported information revealed that most cases were likely not functionally significant and the true prevalence of myocarditis is likely much lower (<2%). At least one acute, potentially COVID-19-related cardiovascular histopathologic finding, such as macro or microvascular thrombi, inflammation, or intraluminal megakaryocytes, was reported in 47.8% of cases. Significant differences in reporting of histopathologic findings occurred between studies indicating strong biases in observations and the need for more consistency in reporting. In conclusion, across 277 cases, COVID-19-related cardiac histopathological findings, are common, while myocarditis is rare.


Assuntos
COVID-19/complicações , Miocardite/patologia , Miocárdio/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Autopsia , COVID-19/mortalidade , COVID-19/virologia , Causas de Morte , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocardite/mortalidade , Miocardite/virologia , Fatores de Risco , Adulto Jovem
9.
ESC Heart Fail ; 8(1): 37-46, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33350605

RESUMO

AIMS: COVID-19, a respiratory viral disease causing severe pneumonia, also affects the heart and other organs. Whether its cardiac involvement is a specific feature consisting of myocarditis, or simply due to microvascular injury and systemic inflammation, is yet unclear and presently debated. Because myocardial injury is also common in other kinds of pneumonias, we investigated and compared such occurrence in severe pneumonias due to COVID-19 and other causes. METHODS AND RESULTS: We analysed data from 156 critically ill patients requiring mechanical ventilation in four European tertiary hospitals, including all n = 76 COVID-19 patients with severe disease course requiring at least ventilatory support, matched to n = 76 from a retrospective consecutive patient cohort of severe pneumonias of other origin (matched for age, gender, and type of ventilator therapy). When compared to the non-COVID-19, mortality (COVID-19 = 38.2% vs. non-COVID-19 = 51.3%, P = 0.142) and impairment of systolic function were not significantly different. Surprisingly, myocardial injury was even more frequent in non-COVID-19 (96.4% vs. 78.1% P = 0.004). Although inflammatory activity [C-reactive protein (CRP) and interleukin-6] was indifferent, d-dimer and thromboembolic incidence (COVID-19 = 23.7% vs. non-COVID-19 = 5.3%, P = 0.002) driven by pulmonary embolism rates (COVID-19 = 17.1% vs. non-COVID-19 = 2.6%, P = 0.005) were higher. CONCLUSIONS: Myocardial injury was frequent in severe COVID-19 requiring mechanical ventilation, but still less frequent than in similarly severe pneumonias of other origin, indicating that cardiac involvement may not be a specific feature of COVID-19. While mortality was also similar, COVID-19 is characterized with increased thrombogenicity and high pulmonary embolism rates.


Assuntos
COVID-19/complicações , Cardiomiopatias/etiologia , Doença Aguda , Idoso , COVID-19/mortalidade , COVID-19/terapia , Cardiomiopatias/mortalidade , Estudos de Casos e Controles , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Miocardite/etiologia , Miocardite/mortalidade , Pneumonia/complicações , Respiração Artificial , Estudos Retrospectivos , Centros de Atenção Terciária
10.
Signal Transduct Target Ther ; 5(1): 287, 2020 12 11.
Artigo em Inglês | MEDLINE | ID: mdl-33303763

RESUMO

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.


Assuntos
Síndrome da Liberação de Citocina , Ecocardiografia , Eletrocardiografia , Coração Auxiliar , Miocardite , Biópsia , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/diagnóstico , Síndrome da Liberação de Citocina/mortalidade , Síndrome da Liberação de Citocina/terapia , Humanos , Miocardite/diagnóstico , Miocardite/etiologia , Miocardite/mortalidade , Miocardite/terapia
11.
Medicina (Kaunas) ; 56(12)2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33317101

RESUMO

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.


Assuntos
COVID-19/complicações , COVID-19/tratamento farmacológico , COVID-19/terapia , Miocardite/virologia , SARS-CoV-2 , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/uso terapêutico , Alanina/análogos & derivados , Alanina/uso terapêutico , Antivirais/uso terapêutico , COVID-19/virologia , Humanos , Imunização Passiva , Miocardite/mortalidade , Miocardite/terapia , Esteroides/uso terapêutico
12.
Medicine (Baltimore) ; 99(48): e23062, 2020 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-33235067

RESUMO

To explore the clinical characteristics of non-pediatric patients with acute fulminant myocarditis (AFM) and evaluate the treatment effects of astragalus injection on this disease.A total of 54 AFM patients were screened out from 586 patients with acute myocarditis, admitted to the department of cardiology between January 2011 to June 2018. The demographic and clinical data, investigations, treatments, and short-term outcomes were collected and retrospectively analyzed.The mean age of the 54 AFM patients was 34 ±â€Š16.5 years old (range: 13-70 years), including 24 (44.5%) men and 30 (55.5%) women, with a high incidence in 2 age groups: 13-19 and 40-49 years old, despite an inverse trend to the increase of age. All these cases were admitted in emergency conditions: 26 (48.1%) cardiogenic shock, 18 (33.4%) malignant arrhythmias, 8 (14.8%) severe heart failure, and 2 (3.7%) acute pericardial tamponade. Apart from first-aid measures, 37 (68.5%) patients received astragalus injection. During hospitalization, 11 (20.4%) patients died, and 4 (36.3%) of them were from astragalus group while 7 (63.7%) of them from without-astragalus group (P=0.03). Furthermore, the levels of cardiac injury biomarkers, renal function and left ventricular ejection fraction of astragalus group were significantly improved compared with those of without-astragalus group at discharge (all P < .05).Middle-aged people were also prone to AFM. And cardiac shock was the most common, while acute pericardial tamponade was a rare presentation in non-pediatric AFM patients. Astragalus was a potential adjuvant medicine for the treatment of AFM.


Assuntos
Antivirais/uso terapêutico , Astrágalo (Planta) , Medicamentos de Ervas Chinesas/uso terapêutico , Miocardite/tratamento farmacológico , Extratos Vegetais/uso terapêutico , Adolescente , Adulto , Idoso , Antivirais/administração & dosagem , Medicamentos de Ervas Chinesas/administração & dosagem , Feminino , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Miocardite/mortalidade , Fitoterapia , Extratos Vegetais/administração & dosagem , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
13.
J Am Heart Assoc ; 9(23): e018306, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33190570

RESUMO

Background Myocarditis attributable to immune checkpoint inhibitor (ICI) therapy is a potentially fatal immune-related adverse event. Limited data have suggested an association between baseline and on-treatment absolute lymphocyte count (ALC) and neutrophil/lymphocyte ratio (NLR) and the development of other immune-related adverse events; there are no data characterizing the role of ALC and NLR in ICI-associated myocarditis. Methods and Results This was a case control study of 55 patients with ICI myocarditis and 55 controls without any post-ICI immune-related adverse events. We leveraged clinical testing, where patients underwent routine serial blood counts before and with each ICI cycle to compare the baseline and change in ALC and NLR between cases and controls. The association between the change in these parameters with clinical variables and major adverse cardiac events was also tested. In cases, there was a statistically significant decrease in ALC with myocarditis from baseline (1.6 thousands per cubic milliliter (K/µL); interquartile range, 1.1-1.9 K/µL) to admission (1.1 K/µL; interquartile range, 0.7-1.3 K/µL; P<0.001). Similarly, there was an increase in NLR from baseline (3.5; interquartile range, 2.3-5.4) to admission (6.6; interquartile range, 4.5-14.1; P<0.001). There was no statistically significant change in controls. In follow-up, there were 20 events; larger decreases in ALC (44.6% versus 18.2%; P<0.001) or increases in NLR (156.5% versus 65.1%; P=0.019) were associated with major adverse cardiac events. Conclusions A reduction in ALC and an increase in NLR was seen with ICI myocarditis. A greater decrease in ALC or increase in NLR was associated with subsequent major adverse cardiac events.


Assuntos
Inibidores de Checkpoint Imunológico/efeitos adversos , Contagem de Linfócitos , Miocardite/sangue , Miocardite/induzido quimicamente , Neutrófilos , Idoso , Estudos de Casos e Controles , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocardite/mortalidade , Valor Preditivo dos Testes , Curva ROC
14.
J Am Heart Assoc ; 9(16): e015351, 2020 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-32787653

RESUMO

Background There is scarce data about the long-term mortality as well as the prognostic value of cardiovascular magnetic resonance and late gadolinium enhancement (LGE) in patients with biopsy-proven viral myocarditis. We sought to investigate: (1) mortality and (2) prognostic value of LGEcardiovascular magnetic resonance (location, pattern, extent, and distribution) in a >10-year follow-up in patients with biopsy-proven myocarditis. Methods and Results Two-hundred three consecutive patients with biopsy-proven viral myocarditis and cardiovascular magnetic resonance were enrolled; 183 patients were eligible for standardized follow-up. The median follow-up was 10.1 years. End points were all-cause death, cardiac death, and sudden cardiac death (SCD). We found substantial long-term mortality in patients with biopsy-proven myocarditis (39.3% all cause, 27.3% cardiac, and 10.9% SCD); 101 patients (55.2%) demonstrated LGE. The presence of LGE was associated with a more than a doubled risk of death (hazard ratio [HR], 2.40; 95% CI], 1.30-4.43), escalating to a HR of 3.00 (95% CI, 1.41-6.42) for cardiac death, and a HR of 14.79 (95% CI, 1.95-112.00) for SCD; all P≤0.009. Specifically, midwall, (antero-) septal LGE, and extent of LGE were highly associated with death, all P<0.001. Septal LGE was the best independent predictor for SCD (HR, 4.59; 95% CI, 1.38-15.24; P=0.01). Conclusions In patients with biopsy-proven viral myocarditis, the presence of midwall LGE in the (antero-) septal segments is associated with a higher rate of mortality (including SCD) compared with absent LGE or other LGE patterns, underlining the prognostic benefit of a distinct LGE analysis in these patients.


Assuntos
Imagem Cinética por Ressonância Magnética , Miocardite/diagnóstico por imagem , Miocardite/mortalidade , Adulto , Idoso , Biópsia , Causas de Morte , Meios de Contraste , Morte Súbita Cardíaca , Infecções por Vírus Epstein-Barr/mortalidade , Feminino , Seguimentos , Gadolínio , Genoma Viral , Herpesvirus Humano 4/genética , Humanos , Aumento da Imagem , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Miocardite/patologia , Miocardite/virologia , Miocárdio/patologia , Infecções por Parvoviridae/mortalidade , Parvovirus B19 Humano/genética , Fatores de Tempo
15.
Cochrane Database Syst Rev ; 8: CD004370, 2020 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-32835416

RESUMO

BACKGROUND: This is an update of a previous review. Case reports and case series have described dramatic responses to intravenous immunoglobulin (IVIG) in people with presumed viral myocarditis, and its administration has become commonplace. OBJECTIVES: The primary objective of this review was to compare event-free (death, requirement for a cardiac transplant, or placement of a left ventricular assist device) or overall (death) survival of adults and children with presumed viral myocarditis treated with IVIG versus those who did not receive IVIG. A secondary objective was to determine if a group of patients with presumed viral myocarditis could be identified (on the basis of age, duration of symptoms, acuity of onset of symptoms, cardiac function at presentation, virological results, or the presence or absence of histological evidence of acute myocarditis on cardiac biopsy in patients in whom a biopsy was performed) who would be the most likely to benefit from IVIG. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, DARE, CINAHL, Web of Science Core Collection, and LILACS in July 2019, and two trial registries in November 2019. We contacted authors of trials and checked reference lists of relevant papers. We applied no language restrictions. SELECTION CRITERIA: We included studies if (1) participants had a clinical diagnosis of acute myocarditis with a left ventricular ejection fraction (LVEF) ≤ 0.45, left ventricular end-diastolic diameter (LVEDD) > 2 standard deviations (SDs) above the norm, or a left ventricular shortening fraction (LVSF) > 2 SDs below the mean, with duration of cardiac symptoms < 6 months; (2) participants had no evidence of non-infectious or bacterial cardiac disease; and (3) participants were randomly assigned to receive at least 1 g/kg of IVIG versus no IVIG or placebo. We excluded studies if (1) participants had received immunosuppression before outcome assessment; or (2) onset of myocarditis was reported to have occurred < 6 months postpartum. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and extracted data. We assessed risk of bias with the Cochrane 'Risk of bias' tool. We conducted meta-analysis for two outcomes (overall survival and improvement in LVEF) with two adult trials. Other meta-analyses were not possible because only three relevant trials were included, and researchers analysed markedly different populations and used different outcome measures. MAIN RESULTS: In this update we added two trials to the two previously included trials. A quasi-randomised trial was previously included due to a paucity of evidence from randomised trials; however, with the addition of two new randomised trials, it was removed from this update. For two adult trials, the overall risk of bias was unclear with very low-certainty evidence for all outcomes. The first trial studied 62 adults with recent-onset dilated cardiomyopathy randomly assigned to receive IVIG or an equivalent volume of 0.1% albumin in a blinded fashion. The effect on event-free survival between groups was uncertain (risk ratio (RR) of any event 1.76, 95% confidence interval (CI) 0.48 to 6.40). The second trial studied 41 adults with acute myocarditis randomised to either high-dose IVIG (1 to 2 g/kg over two days) or no treatment. The IVIG group reported greater survival time after 60 days (no raw data, P < 0.01), but the evidence is uncertain. We pooled the reported number of deaths in both trials, with no evidence of a difference between groups (RR 0.91, 95% CI 0.23 to 3.62, I2 = 31%, very low-certainty evidence). The evidence on the effect of IVIG treatment on LVEF (pooled mean difference (MD) -0.01, 95% CI -0.06 to 0.05) after 12 months and an unknown time frame is uncertain. The results for functional capacity, assessed by peak oxygen consumption at 12 months, were uncertain (MD -0.80, 95% CI -4.57 to 2.97). The results for infusion-related side effects were also uncertain due to a very large CI (RR 20.29, 95% CI 1.25 to 329.93). Lastly, there was uncertain evidence addressing failure to attain complete recovery (RR 0.46, 95% CI 0.19 to 1.14).  Evidence for improvement in LVEDD, left ventricular shortening fraction, and hospitalisation status in adults was not reported.  In the single included paediatric trial, the overall risk of bias was low with very low-certainty evidence for all outcomes. The trial included 86 children in Egypt presenting with acute myocarditis. Children were randomly assigned to 1 g/kg IVIG daily for two consecutive days or placebo followed by echocardiography one and six months post randomisation for recording of LVEDD and LVSF. The evidence for overall survival after six months was uncertain (risk of death RR 0.48, 95% CI 0.20 to 1.15). The evidence was also uncertain for improvement in LVEDD and LVSF after six months (LVEDD MD -4.00, 95% CI -9.52 to 1.52; LVSF no raw data).  Evidence for improvement in LVEF, functional capacity, side effects, complete recovery, and hospitalisation status in children was not reported.  AUTHORS' CONCLUSIONS: Evidence from two trials of very low certainty and with unclear risk of bias provides contradictory evidence on the use of IVIG in the treatment of adults with presumed viral myocarditis. One trial reported that use of IVIG results in longer survival time after 60 days, whilst the other trial found that IVIG does not provide an appreciable benefit. The evidence of a difference in event-free or overall survival, LVEDD, or LVSF is of very low certainty in a single paediatric trial with a low risk of bias. Until higher-quality studies with low risk of bias and larger sample sizes have demonstrated benefit in a particular group of patients, the evidence for treatment with IVIG for presumed viral myocarditis is uncertain. Further studies of the pathophysiology of myocarditis would lead to improved diagnostic criteria, which would facilitate future research.


Assuntos
Imunoglobulinas Intravenosas/uso terapêutico , Miocardite/terapia , Viroses/terapia , Doença Aguda , Adulto , Viés , Criança , Humanos , Miocardite/mortalidade , Miocardite/virologia , Intervalo Livre de Progressão , Ensaios Clínicos Controlados Aleatórios como Assunto , Volume Sistólico/efeitos dos fármacos , Viroses/mortalidade
18.
Fetal Pediatr Pathol ; 39(3): 263-268, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32401577

RESUMO

Background: Cardiac damage is frequently referred to in patients with SARS-CoV-2, is usually diagnosed by enzyme elevations, and is generally thought to be due to underlying coronary artery disease. There are references to cardiomyopathies accompanying coronavirus, but there has been no histologic confirmation.Case report: A previously healthy 17 year male old presented in full cardiac arrest to the emergency department after a 2 day history of headache, dizziness, nausea and vomiting. Autopsy demonstrated an enlarged flabby heart with eosinophilic myocarditis. There was no interstitial pneumonia or diffuse alveolar damage. Postmortem nasopharyngeal swabs detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known to cause coronavirus disease 2019 (COVID-19). No other cause for the eosinophilic myocarditis was elucidated.Conclusion: Like other viruses, SARS-CoV-2 may be associated with fulminant myocarditis.


Assuntos
Infecções por Coronavirus/mortalidade , Eosinofilia/mortalidade , Miocardite/mortalidade , Miocardite/virologia , Pneumonia Viral/mortalidade , Adolescente , Betacoronavirus , COVID-19 , Infecções por Coronavirus/complicações , Eosinofilia/complicações , Evolução Fatal , Parada Cardíaca/complicações , Parada Cardíaca/virologia , Humanos , Masculino , Miocardite/complicações , Pandemias , Pneumonia Viral/complicações , SARS-CoV-2
19.
Heart ; 106(13): 992-1000, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32447308

RESUMO

OBJECTIVE: We assessed the diagnostic and prognostic implications of early cardiac magnetic resonance (CMR), CMR-based deformation imaging and conventional risk factors in patients with troponin-positive acute chest pain and non-obstructed coronary arteries. METHODS: In total, 255 patients presenting between 2009 and 2019 with troponin-positive acute chest pain and non-obstructed coronary arteries who underwent CMR in ≤7 days were followed for a clinical endpoint of all-cause mortality. Cine movies, T2-weighted and late gadolinium-enhanced images were evaluated to establish a diagnosis of the underlying heart disease. Further CMR analysis, including left ventricular strain, was carried out. RESULTS: CMR (performed at a mean of 2.7 days) provided the diagnosis in 86% of patients (54% myocarditis, 22% myocardial infarction (MI) and 10% Takotsubo syndrome and myocardial contusion (n=1)). The 4-year mortality for a diagnosis of MI, myocarditis, Takotsubo and normal CMR patients was 10.2%, 1.6%, 27.3% and 0%, respectively. We found a strong association between CMR diagnosis and mortality (log-rank: 24, p<0.0001). Takotsubo and MI as the diagnosis, age, hypertension, diabetes, female sex, ejection fraction, stroke volume index and most of the investigated strain parameters were univariate predictors of mortality; however, in the multivariate analysis, only hypertension and circumferential mechanical dispersion measured by strain analysis were independent predictors of mortality. CONCLUSIONS: CMR performed in the early phase establishes the proper diagnosis in patients with troponin-positive acute chest pain and non-obstructed coronary arteries and provides additional prognostic factors. This may indicate that CMR could play an additional role in risk stratification in this patient population.


Assuntos
Angina Pectoris/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética , Contusões Miocárdicas/diagnóstico por imagem , Infarto do Miocárdio/diagnóstico por imagem , Miocardite/diagnóstico por imagem , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Troponina/sangue , Adulto , Idoso , Angina Pectoris/sangue , Angina Pectoris/mortalidade , Angina Pectoris/terapia , Biomarcadores/sangue , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Bases de Dados Factuais , Diagnóstico Diferencial , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Contusões Miocárdicas/sangue , Contusões Miocárdicas/mortalidade , Contusões Miocárdicas/terapia , Infarto do Miocárdio/sangue , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Miocardite/sangue , Miocardite/mortalidade , Miocardite/terapia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Cardiomiopatia de Takotsubo/sangue , Cardiomiopatia de Takotsubo/mortalidade , Cardiomiopatia de Takotsubo/terapia , Fatores de Tempo , Adulto Jovem
20.
J Cardiovasc Transl Res ; 13(3): 284-295, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32270467

RESUMO

Myocarditis is as an important cause of sudden cardiac death (SCD) among athletes. The incidence of SCD ascribed to myocarditis did not change after the introduction of pre-participation screening in Italy, due to the transient nature of the disease and problems in the differential diagnosis with the athlete's heart. The arrhythmic burden and the underlying mechanisms differ between the acute and chronic setting, depending on the relative impact of acute inflammation versus post-inflammatory myocardial fibrosis. In the acute phase, ventricular arrhythmias vary from isolated ventricular ectopic beats to complex tachycardias that can lead to SCD. Atrioventricular blocks are typical of specific forms of myocarditis, and supraventricular arrhythmias may be observed in case of atrial inflammation. Athletes with acute myocarditis should be temporarily restricted from physical exercise, until complete recovery. However, ventricular tachycardia may also occur in the chronic phase in the context of post-inflammatory myocardial scar.


Assuntos
Arritmias Cardíacas/etiologia , Atletas , Morte Súbita Cardíaca/etiologia , Miocardite/complicações , Resistência Física , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/prevenção & controle , Nível de Saúde , Humanos , Miocardite/mortalidade , Miocardite/fisiopatologia , Miocardite/terapia , Prognóstico , Medição de Risco , Fatores de Risco
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