The evolving approach to paediatric myocarditis: a review of the current literature

Abstract

Paediatric myocarditis remains challenging from the perspectives of diagnosis and management. Multiple aetiologies exist and the majority of cases appear to be related to viral illnesses. Enteroviruses are believed to be the most common cause, although cases related to adenovirus may be more frequent than suspected. The clinical presentation is extremely varied, ranging from asymptomatic to sudden unexpected death. A high index of suspicion is crucial. There is emerging evidence to support investigations such as serum N-terminal B-type natriuretic peptide levels, as well as cardiac magnetic resonance imaging as adjuncts to the clinical diagnosis. In the future, these may reduce the necessity for invasive methods, such as endomyocardial biopsy, which remain the gold standard. Management generally includes supportive care, consisting of cardiac failure medical management, with the potential for mechanical support and cardiac transplantation. Treatments aimed at immunosuppression remain controversial. The paediatric literature is extremely limited with no conclusive evidence to support or refute these strategies. This article summarises the current literature regarding aetiology, clinical presentation, diagnosis, and management of myocarditis in paediatric patients.

Diagnosis and Treatment of Myocarditis in Children in the Current Era

“…78 Acute myocarditis in children has been associated with a good prognosis with a good chance for ultimate recovery of left ventricular dysfunction. 12,74,77,79,80 Within the North American Pediatric Cardiomyopathy Registry (PCMR; 43 Figure 1), 372 myocarditis patients diagnosed by biopsy (n=119) or clinical criteria (n=253) were compared with 1123 patients diagnosed with idiopathic dilated cardiomyopathy. Outcomes were similar in the biopsy and clinically diagnosed myocarditis patients and substantially better than in children diagnosed with idiopathic dilated cardiomyopathy.…”

Eosinophilic cardiac disease: Molecular, clinical and imaging aspects

“…Because corticosteroid therapy inhibits the degranulation of eosinophils, it has been proposed as a first-line treatment for eosinophilic myocarditis in order to limit myocardial necrosis. However, the efficacy of corticosteroids remains controversial [32,33]. In case of fulminant heart failure, mechanical support may be necessary.…”

Changes in cardiac output and stroke volume as measured by non-invasive CO monitoring in infants with RSV bronchiolitis

“…Of these, 5 infants were recruited from the MICU, 6 were recruited from the ICP, and 4 from the Inpatient Units. There were 10 males and 5 females with a median age of 2.0 (0.4-18) months, median weight of 5.8 (3)(4)(5)(6)(7)(8)(9)(10)(11) kg and median height of 60 (50-84) cm. Median time to acute stabilization was 4 (1-6) days, time between initial and final CO recording was 2.5 (0.8-7.2) days and length of hospitalization was 3.6 (1.6-8.9) days.…”

“…Infants with respiratory insufficiency from bronchiolitis may have similar clinical features to infants with congestive heart failure [7], presenting with irritability, fever, tachypnea, tachycardia and a mottled appearance. Although RSV infection seldom causes myocarditis, early detection of impaired cardiac output (CO) can be lifesaving in these infants [8] and similar to other etiologies for myocarditis may require emergent referral for advanced hemodynamic support (e.g., ECMO and heart [9,10]. Consequently, it is important to have the ability to monitor cardiac function in infants with RSV bronchiolitis in order to ensure optimal clinical management.…”