Birtolo LI, Ferranti F, Manzi G, Caputo A, Scoccia G, Bruno K, Galea N, Maestrini V, Chimenti C, Severino P, Pugliese F, Badagliacca R, Vizza CD. From COVID-19 to influenza A - recurrent viral myocarditis and successful immunosuppressive therapy: A case report and review of literature. World J Cardiol 2026; 18(6): 113066 [DOI: 10.4330/wjc.113066]
Corresponding Author of This Article
Lucia Ilaria Birtolo, MD, PhD, Department of Clinical, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Lazio, Italy. luciailaria.birtolo@uniroma1.it
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
case-report
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Birtolo LI, Ferranti F, Manzi G, Caputo A, Scoccia G, Bruno K, Galea N, Maestrini V, Chimenti C, Severino P, Pugliese F, Badagliacca R, Vizza CD. From COVID-19 to influenza A - recurrent viral myocarditis and successful immunosuppressive therapy: A case report and review of literature. World J Cardiol 2026; 18(6): 113066 [DOI: 10.4330/wjc.113066]
Lucia Ilaria Birtolo, Federico Ferranti, Giovanna Manzi, Annalisa Caputo, Gianmarco Scoccia, Katia Bruno, Viviana Maestrini, Cristina Chimenti, Paolo Severino, Francesco Pugliese, Roberto Badagliacca, Carmine Dario Vizza, Department of Clinical, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome 00161, Lazio, Italy
Nicola Galea, Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome 00161, Lazio, Italy
Co-first authors: Lucia Ilaria Birtolo and Federico Ferranti.
Author contributions: Birtolo LI and Ferranti F contributed to the conception and drafting of the case report; Vizza CD provided critical revision of the manuscript; Manzi G, Caputo A, Scoccia G, Bruno K, Galea N, Maestrini V, Chimenti C, Severino P, Pugliese F, and Badagliacca R also participated in the conception, drafting, and critical revision of the report; and all authors approved the final version of the manuscript.
AI contribution statement: AI-based language assistance tools were used during manuscript preparation for English language editing and linguistic refinement. AI tools did not contribute to the study design or interpretation of the results. The scientific content of the manuscript, including all sections of the main text, was conceived, written, critically revised, and approved by the authors. No part of the scientific content was autonomously generated by AI.
Informed consent statement: Written informed consent for publication of this case report and any accompanying images were obtained from the patient.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Lucia Ilaria Birtolo, MD, PhD, Department of Clinical, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Lazio, Italy. luciailaria.birtolo@uniroma1.it
Received: August 14, 2025 Revised: September 14, 2025 Accepted: May 8, 2026 Published online: June 26, 2026 Processing time: 308 Days and 15.5 Hours
Abstract
BACKGROUND
Myocarditis is an inflammatory disease of the myocardium with a highly variable clinical presentation and is often triggered by viral infections. While corticosteroids have historically been used with caution in viral myocarditis due to concerns over impaired viral clearance, recent insights from the coronavirus disease 2019 pandemic suggest that their use may offer clinical benefits in selected cases. Whether such benefits extend to other viral etiologies, including influenza, remains uncertain. We report a case of recurrent viral myocarditis in a young woman, initially following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and later associated with influenza A (H1N1), illustrating diagnostic and therapeutic challenges.
CASE SUMMARY
A previously healthy 27-year-old woman presented with fulminant myocarditis after a paucisymptomatic SARS-CoV-2 infection. The initial episode was characterized by pericardial effusion, rapidly progressing to cardiogenic shock and severe left ventricular dysfunction, requiring veno-arterial extracorporeal membrane oxygenation. Empirical high-dose corticosteroid therapy, remdesivir, and monoclonal anti-SARS-CoV-2 antibodies led to complete recovery of cardiac function. Two years later, the patient developed recurrent myocarditis triggered by H1N1, presenting with chest pain, elevated cardiac biomarkers, and severe reduction in ejection fraction. Cardiac magnetic resonance confirmed acute myocarditis with severe left ventricular dysfunction. High-dose corticosteroids and levosimendan were administered, resulting in progressive improvement without the need for mechanical support. At discharge, following both episodes, the patient was asymptomatic and had a complete recovery of the left ventricular ejection fraction. Genetic testing was performed to investigate possible predisposition.
CONCLUSION
This case highlights the diagnostic and therapeutic challenges of recurrent viral myocarditis, as well as the potential role of immunosuppression.
Core Tip: We present the case of a young woman who experienced two episodes of fulminant viral myocarditis following distinct viral infections (severe acute respiratory syndrome coronavirus 2 and influenza A), both of which were successfully treated with high-dose corticosteroids. The case raises key questions about the role of immunosuppressive therapy in managing the immune activation triggered by viral infections in myocarditis. The recurrence in the same patient highlights the importance of investigating possible underlying genetic or autoimmune vulnerabilities. This report provides insights that enhance our understanding of the complex relationship between viral triggers, immune response, and patient susceptibility in cases of myocarditis.
