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Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children - "If the resting heart rate is 10 beats per minute above normal this would be an indicator not to train."

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  • Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children - "If the resting heart rate is 10 beats per minute above normal this would be an indicator not to train."

    hat tip Shiloh -

    Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children

    <nobr>Andr?s Bratincs?k, MD, PhD<sup><sub>*</sub></sup></nobr>, <nobr>Howaida G. El-Said, MD, PhD</nobr>, <nobr>John S. Bradley, MD</nobr>, <nobr>Katayoon Shayan, MD</nobr>, <nobr>Paul D. Grossfeld, MD</nobr> and <nobr>Christopher R. Cannavino, MD</nobr> <sup><sub>*</sub></sup> Rady Children's HospitalSan Diego, University of California San Diego, School of Medicine, 3020 Children's Way, MC5004, San Diego, California 92123 (Email: bratiandris@yahoo.com<script type="text/javascript"><!-- var u = "bratiandris", d = "yahoo.com"; document.getElementById("em0").innerHTML = '<a href="mailto:' + u + '@' + d + '">' + u + '@' + d + '<\/a>'//--></script>).

    <hr width="75%" noshade="noshade" size="2">To the Editor: Acute myocarditis is a well-recognized, albeit<sup> </sup>rare, manifestation of numerous viral infections (1) with a<sup> </sup>broad spectrum of symptoms and clinical features (2). Fulminant<sup> </sup>myocarditis may present with fatal arrhythmias, atrioventricular<sup> </sup>block, and/or varying degrees of cardiogenic shock (3). The<sup> </sup>prevalence of myocardial involvement in influenza infection<sup> </sup>ranges from 0 to 11% depending on the diagnostic criteria used<sup> </sup>to define myocarditis (4). Fulminant myocarditis is an uncommon<sup> </sup>complication, typically diagnosed in association with circulatory<sup> </sup>collapse or at autopsy in patients with influenza-associated<sup> </sup>fatal outcomes (5). A few case reports and series (68)<sup> </sup>represent the incidental diagnoses of influenza-associated acute<sup> </sup>fulminant myocarditis, but the true prevalence remains unknown.<sup> </sup> Here we present the first known report of acute myocarditis<sup> </sup>in pediatric population associated with the present pandemic<sup> </sup>H1N1 influenza A virus infection. Four cases occurred within<sup> </sup>a 30-day period, and 3 of them were diagnosed as fulminant myocarditis<sup> </sup>with fatal or near-fatal outcomes.<sup> </sup>
    A retrospective chart review was conducted on all patients admitted<sup> </sup>to Rady Children's HospitalSan Diego with the diagnosis<sup> </sup>of H1N1 influenza A infection during October 2009. Criteria<sup> </sup>for fulminant myocarditis included echocardiographic and clinical<sup> </sup>evidence of severely decreased left ventricular systolic function<sup> </sup>and/or lymphocytic infiltration of the myocardium documented<sup> </sup>at autopsy.<sup> </sup>
    Within a 30-day period, 80 children were admitted with H1N1<sup> </sup>influenza A infection to Rady Children's HospitalSan<sup> </sup>Diego. Serum troponin I and creatine phosphokinase myocardial<sup> </sup>band levels were obtained in 11 children, and echocardiography<sup> </sup>was performed in 8 children. We included 4 H1N1 influenzaassociated<sup> </sup>myocarditis cases based on elevated cardiac enzymes (n = 2),<sup> </sup>significant acute decrease in left ventricular systolic function<sup> </sup>demonstrated by the echocardiogram (n = 3), or histologic evidence<sup> </sup>of severe myocarditis (n = 1) (Fig. 1A). Three children presented<sup> </sup>with fulminant myocarditis, 1 with a fatal outcome and 2 requiring<sup> </sup>extracorporeal membrane oxygenation support. None of the children<sup> </sup>with fulminant myocarditis had evidence of sepsis or bacterial<sup> </sup>infection (negative blood, urine, and tracheal aspirate cultures).<sup> </sup>Two of the 3 children with decreased systolic function experienced<sup> </sup>recovery in 5 to 7 days (Figs. 1E and 1F). All 4 children had<sup> </sup>a positive rapid influenza enzyme immunoassay test result from<sup> </sup>a nasopharyngeal swab sample that was subsequently confirmed<sup> </sup>as H1N1 by reverse-transcriptase polymerase chain reaction performed<sup> </sup>at the San Diego County Department of Health (Fig. 1A).<sup> </sup>
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    <center><table cellpadding="0" cellspacing="0" width="95%"><tbody><tr bgcolor="#e1e1e1"><td><table cellpadding="2" cellspacing="2"> <tbody><tr bgcolor="#e1e1e1"><td align="center" bgcolor="#ffffff" valign="top">
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    </nobr> </td><td align="left" valign="top"> Figure 1 Acute Myocarditis Associated With H1N1 Influenza A Infection (A) Demographics, symptoms, tests, and complications of 4 children with influenza-associated acute myocarditis. (B) Severe myocardial damage demonstrated in the interventricular septum with mononuclear cellular infiltration. (C) Enlarged area from B shows a large number of lymphocytes and macrophages infiltrating the myocardium (arrow) with surrounding cardiomyocyte necrosis. (D) Lymphocytic infiltration in the area of the atrioventricular (AV) node (*). (E) Severe dilation and poor systolic function of the left ventricle (LV) on a 2-dimensional and M-mode echocardiogram with an ejection fraction (EF) of 12%. (F) Resolution of left ventricular (LV) systolic function after 5 days of extracorporeal membrane oxygenation (ECMO) support demonstrated on 2-dimensional and M-mode echocardiogram with an improved EF of 68%. BP = blood pressure; bpm = beats/min; EIA = enzyme immunoassay; HR = heart rate; IVS = interventricular septum; LA = left atrium; RA = right atrium; rtPCR = reverse-transcripase polymerase chain reaction; RV = right ventricle.

    </td></tr></tbody></table> </td></tr></tbody></table></center>
    Fulminant myocarditis due to viral infection is an uncommon<sup> </sup>form of acute myocarditis (2,3). Influenza A virusassociated<sup> </sup>fulminant myocarditis is exceedingly rare, with only a few cases<sup> </sup>reported in the literature (4,5). We report the first 4 cases<sup> </sup>of acute myocarditis in children associated with the pandemic<sup> </sup>H1N1 influenza A virus, all occurring within a 30-day period.<sup> </sup> Our tertiary care hospital serves a geographic region that includes<sup> </sup>approximately 800,000 children. During the past 3 years, there<sup> </sup>was an annual average of 2 cases of acute myocarditis due to<sup> </sup>suspected viral etiology, none of which had evidence of influenza<sup> </sup>infection. Within a 30-day period in October 2009, there were<sup> </sup>3 cases of acute fulminant myocarditis and 1 case of acute perimyocarditis<sup> </sup>at Rady Children's HospitalSan Diego, all associated<sup> </sup>with confirmed H1N1 influenza A infection. There was serologic,<sup> </sup>echocardiographic, and/or histologic evidence of myocardial<sup> </sup>involvement in all cases (Fig. 1A). Three children had echocardiographic<sup> </sup>evidence of an acutely decreased myocardial function. One child<sup> </sup>died likely due to acute atrioventricular block, as suggested<sup> </sup>by severe lymphocytic infiltration of the conduction system<sup> </sup>(Figs. 1B to 1D). Two children required extracorporeal membrane<sup> </sup>oxygenation support with gradual improvement of the ventricular<sup> </sup>systolic function over a 1-week period (Figs. 1E and 1F), which<sup> </sup>is typically observed in patients with fulminant myocarditis<sup> </sup>(2).<sup> </sup>
    The prevalence of influenza-associated fulminant myocarditis<sup> </sup>is not known because of the lack of comprehensive screening,<sup> </sup>with only a handful of clinical cases and autopsy findings reported<sup> </sup>in the literature (58). Our documented 4 cases within<sup> </sup>a 30-day period, compared with our previous experience, raise<sup> </sup>the possibility that the novel H1N1 influenza A virus is more<sup> </sup>commonly associated with a severe form of myocarditis than previously<sup> </sup>encountered influenza strains.<sup> </sup>
    Our observations warrant a high index of suspicion for myocarditis<sup> </sup>in children with H1N1 influenza A infection. Early detection<sup> </sup>and aggressive management are paramount. Timely intervention<sup> </sup>with circulatory support may decrease morbidity and mortality,<sup> </sup>with the potential for a favorable cardiac prognosis.<sup> </sup>
    <sup> </sup>
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    <table bgcolor="#e1e1e1" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr><td align="left" bgcolor="#ffffff" width="5%" valign="middle"></td> <th align="left" width="95%" valign="middle"> Footnotes </th></tr></tbody></table>
    <!-- null --> Please note: Leslie Cooper, MD, served as Guest Editor for this<sup> </sup>paper. Drs. Bratincs?k, El-Said, Grossfeld, and Cannavino<sup> </sup>contributed equally to this report.<sup> </sup>
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    <table bgcolor="#e1e1e1" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr><td align="left" bgcolor="#ffffff" width="5%" valign="middle"></td> <th align="left" width="95%" valign="middle"> References </th></tr></tbody></table> <table align="right" border="1" cellpadding="5"><tbody><tr><th align="left"> Top
    References
    </th></tr></tbody></table>
    <!-- null -->1. Bowles NE, Ni J, Kearney DL, et al. Detection of viruses in myocardial tissues by polymerase chain reaction. Evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol 2003;42:466-472.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:1" --><nobr>[Abstract/Free Full Text]</nobr><!-- /HIGHWIRE -->
    <!-- null -->2. Lieberman EB, Hutchins GM, Herskowitz A, Rose NR, Baughman KL. Clinicopathologic description of myocarditis J Am Coll Cardiol 1991;18:1617-1626.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:2" -->[Abstract]<!-- /HIGHWIRE -->
    <!-- null -->3. Cooper Jr LT. Myocarditis N Engl J Med 2009;360:1526-1538.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:3" --><nobr>[Free Full Text]</nobr><!-- /HIGHWIRE -->
    <!-- null -->4. Mamas MA, Fraser D, Neyses L. Cardiovascular manifestations associated with influenza virus infection Int J Cardiol 2008;130:304-309.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:4" -->[CrossRef][Web of Science][Medline]<!-- /HIGHWIRE -->
    <!-- null -->5. Guarner J, Paddock CD, Shieh WJ, et al. Histopathologic and immunohistochemical features of fatal influenza virus infection in children during the 20032004 season Clin Infect Dis 2006;43:132-140.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:5" -->[CrossRef][Web of Science][Medline]<!-- /HIGHWIRE -->
    <!-- null -->6. Walker OJ. Pathology of influenza-pneumonia J Lab Clin Med 1919;5:22.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:6" --><!-- /HIGHWIRE -->
    <!-- null -->7. Adams CW. Postviral myopericarditis associated with the influenza virus: report of eight cases Am J Cardiol 1959;4:56-67.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:7" -->[CrossRef][Web of Science][Medline]<!-- /HIGHWIRE -->
    <!-- null -->8. Onitsuka H, Imamura T, Miyamoto N, et al. Clinical manifestations of influenza a myocarditis during the influenza epidemic of winter 19981999 J Cardiol 2001;37:315-323.<!-- HIGHWIRE ID="0:2010:j.jacc.2010.01.004v1:8" -->[Medline]

    http://content.onlinejacc.org/cgi/co....2010.01.004v1
    Last edited by kiwibird; December 31, 2020, 06:35 AM.

  • #2
    Re: Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children

    Interaction between infection and exercise with special reference to myocarditis and the increased frequency of sudden deaths among young Swedish orienteers 1979-92.

    Friman G, Larsson E, Rolf C.

    Department of Infectious Diseases and Clinical Microbiology, Uppsala University Hospital, Sweden.

    Infection and fever evoke a cytokine-mediated host response resulting in negative nitrogen balance, muscle protein degradation, which includes the skeletal muscles as well as the heart muscle, and deteriorated muscle function. Physical training has an opposite effect. Moderate physical training also stimulates the immune system, whereas exhaustive and longlasting exercise is followed by a temporary immunodeficiency and an increased susceptibility to respiratory tract infections. Exercise in the acute phase of an infection may promote complications including myocarditis. Exercise in myocarditis is associated with increased organism-associated as well as immune mediated tissue damage. An increased sudden death (SUD) rate among young Swedish male orienteers existed in 1979-92, suggesting (a) common underlying cause(s). Myocarditis was one of the most conspicuous histopathological features. Chlamydia pneumoniae, or a similar organism cross reacting in diagnostic tests, is hypothesized to be a factor causing this increased death rate. High frequency of intense exercise sessions, which was a common practice among the deceased, may have been immunosuppressive, promoting the development of severe myocardial disease.
    Infection and fever evoke a cytokine-mediated host response resulting in negative nitrogen balance, muscle protein degradation, which includes the skeletal muscles as well as the heart muscle, and deteriorated muscle function. Physical training has an opposite effect. Moderate physical training also …


    Many many articles detail the risk factors associated with heart failure and exercise. When sick with influenza it would seem sensible to curtail exercise. "The dead children thread" showed that many of the young people succumbed quickly and unexpectedly after playing sports. Myocarditis was also associated with many of the deaths in "army training camps" in Malaysia.



    "The only security we have is our ability to adapt."

    Comment


    • #3
      Re: Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children

      Has this been the case in Japan?
      "The only security we have is our ability to adapt."

      Comment


      • #4
        Re: Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children

        Winter colds and other viruses can cause havoc with carefully planned fitness regimes. Sam Murphy on when it's safe to resume exercise


        "Elite athletes check their resting hear rate every day," says Dr. Mark Wotherspoon, a sports physician with the English Institute of Sport. "If the resting heart rate is 10 beats per minute above normal this would be an indicator not to train."

        The article differentiates between illnesses that have "above the neck symptoms" and "below the neck symptoms". Any illness with fever, vomiting, cough or congestion should be treated seriously and exercise postponed until resting heart beat is back to normal. Forcing yourself to exercise when ill can damage your heart - and cause myocarditis.

        Parents and coaches should make a habit of logging their athletes/students resting heart rate so they can check after a bout of illness if exercise should be resumed.
        "The only security we have is our ability to adapt."

        Comment


        • #5
          Originally posted by kiwibird View Post
          Re: Study - Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children

          Winter colds and other viruses can cause havoc with carefully planned fitness regimes. Sam Murphy on when it's safe to resume exercise


          "Elite athletes check their resting hear rate every day," says Dr. Mark Wotherspoon, a sports physician with the English Institute of Sport. "If the resting heart rate is 10 beats per minute above normal this would be an indicator not to train."

          The article differentiates between illnesses that have "above the neck symptoms" and "below the neck symptoms". Any illness with fever, vomiting, cough or congestion should be treated seriously and exercise postponed until resting heart beat is back to normal. Forcing yourself to exercise when ill can damage your heart - and cause myocarditis.

          Parents and coaches should make a habit of logging their athletes/students resting heart rate so they can check after a bout of illness if exercise should be resumed.
          "Elite athletes check their resting hear rate every day," says Dr. Mark Wotherspoon, a sports physician with the English Institute of Sport. "If the resting heart rate is 10 beats per minute above normal this would be an indicator not to train."

          True as ever with any illness - even more so if Coronavirus Covid-19 causes myocarditis even in the young.
          "The only security we have is our ability to adapt."

          Comment

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