Retrospective Study
Copyright ©The Author(s) 2019.
World J Clin Cases. Mar 6, 2019; 7(5): 548-561
Published online Mar 6, 2019. doi: 10.12998/wjcc.v7.i5.548
Table 1 Baseline characteristics at the time of hospital admission
Clinical and demographic datan = 42
AgeMedian (IQR) yr: 8 (1.5-12)
Male:Female gender2.23
EvolutionMedian (IQR) days from initial symptoms: 5 (2-10)
Visits to ED previously before diagnosis of myocarditisMedian (IQR) visits prior to admission: 2 (1-2); 1 visit (41), 2 visits (36), 3 visits (9), more than 3 visits (14)
Presenting symptoms (%)Previous viral infection (69); Chest pain (40); Respiratory tract symptoms (cough, apnea, rhinorrhea) (38); Shortness of breath (35); Gastrointestinal tract symptoms (vomiting, abdominal pain, diarrhea) (33); Fever (31); Weakness, exercise or feeding intolerance (21); Palpitations (16); Lethargy (12); Syncope (4)
Physical exam (%)Tachycardia (57); Tachypnea (52); Evidence of respiratory tract infection (44); Respiratory distress (35); Abnormal lung auscultation (31); Murmur (26); Systolic hypotension (24); Poor perfusion or diminished pulses (21); Gallop rhythm (20); Hepatomegaly (20); Edema (7); Cyanosis (2)
Cardiac syndrome (%)ACS-like (34); Fulminant myocarditis (29); Congestive heart failure (23); Dysrhythmia (14)
Complementary exams
Laboratory (%)CRP > 60 mg/L (16); Troponin T > 10 ng/L (62); NT-proBNP > 600 pg/mL (40)
Chest X-Ray (%)Cardiomegaly (35); Pulmonary edema (28); Pulmonary infiltrate (4%); Pleural effusion (2.5%)
ECG (%)Abnormal ECG (93); Sinus tachycardia (61); Ischemic changes (57); Low voltage (50); SVT (2.5); VT (7); AVB (2.5); prolonged QT interval (2.5%)
Echocardiography (%)Abnormal echocardiography (88): LV systolic dysfunction (50): severe (14), moderate (16), mild (20); Biventricular systolic dysfunction (10); Segmental wall motion abnormalities (38); LV dilation (43); Mitral regurgitation (69); Pericardial effusion (59)
Cardiac MRI (%)MRI performed (50); Median days to realization from admission, 5 (3-9); Lake Louis criteria positive (86), equivocal (10), negative (4)
Microbiology (%)Positive microbiology (47): Coxsakie (30); Parvovirus B19 (20); Adenovirus (15); EBV (15); CMV (10); Mycoplasma (10)
Treatment (%)Any treatment (71): Diuretics (69); ACEI (69); Beta-blockers (64); Digoxin (14) Spironolactone (14); Antiarrhythmic (5); Inotropic support (35); Mechanical Ventilation (26); ECMO/VAD (2.5); Pacemaker (2.5)
Outcomes (%)Hospitalization length of stay (d): Median 6 (IQR 3-13); Death (5), transplant (0)
Poor early outcomes: Death, transplant, or LV systolic dysfunction/dilation at discharge (43)
Poor late outcomes: Death, transplant or LV systolic dysfunction/dilation after 1 yr of follow-up (16); Spontaneous LV function recovery during first year after diagnosis (69)
IQR: Interquartile range; GI: Gastrointestinal; SCD: Sudden cardiac death; ACS: Acute coronary syndrome; CRP: C-reactive protein; NT-proBNP: N-terminal pro-brain natriuretic peptide; ECG: Electrocardiogram; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; AVB: Atrioventricular block; LV: Left ventricle; MRI: Magnetic resonance imaging; EBV: Epstein-Barr virus; CMV: cytomegalovirus; ACEI: Angiotensin-converting-enzyme inhibitors; ECMO: Extracorporeal membrane oxygenation; VAD: Ventricular assist device.
Table 2 Comparison between patients with acute coronary syndrome-like and fulminant myocarditis
VariableACS-like (n = 14; 33%)No ACS-like (n = 28; 66%)P valueFM (n = 12; 28%)No FM (n = 30; 78%)P value
Age (yr), median (IQR)11 (5-12.5)1.6 (1-8)< 0.00110 (2-13)1.7 (0.9-3)< 0.001
Male sex, n (%)19 (71)19 (67)0.8139 (75)20 (66)0.598
Days from initial symptoms, median (IQR)2 (1-3)8.5 (4-12)0.0059 (4.5-11)4 (2-10)0.017
Visits prior to admission, median (IQR)1 (1-1)2 (2-3)< 0.0012.5 (2-3)1 (1-1)< 0.001
Viral prodromal, n (%)9 (31)5 (38)0.6379 (31)3 (23)0.598
Altered ECG, n (%)14 (100)25 (89)0.20412 (100)27 (90)0.256
CPR (mg/dl), median (IQR)5 (2.5-188)3 (2-144)0.17929 (3-203)3 (2-144)0.095
Troponin T (ng/mL), median (IQR)466 (89-800)51 (4-353)0.041134 (71-431)70 (4-160)0.308
NT-proBNP (pg/mL), median (IQR)137 (78-234)1960 (272-3175)< 0.0012900 (2207-6125)225 (105-561)< 0.001
LVEF (%), median (IQR)65 (62-67)41 (30-53)< 0.00132 (27-36)62 (45-66)< 0.001
LGE in cMRI (n = 21), n (%)10/14 (71)5/7 (71)1.0000/1 (0)15/20 (75)0.105
Positive Microbiology, n (%)9 (64)18 (64)1.0008 (66)19 (63)0.839
Poor outcomes, n (%)0 (0)7 (25)0.0415 (41)2 (7)0.006
ACS-like: Acute coronary syndrome; FM: Fulminant myocarditis; IQR: Interquartile range; ECG: Electrocardiogram; CRP: C-reactive protein; NT-proBNP: N-terminal pro-brain natriuretic peptide; LVEF: Left ventricle ejection fraction; LGE: Late gadolinium enhancement; cMRI: Cardiac magnetic resonance imaging.
Table 3 Comparison between patients with good and poor outcomes
VariableEarly outcome (hospital discharge)
Late outcome (1 yr after admission)
Good outcome(n = 24; 57%)Poor outcome(n = 18; 43%)P valueGood outcome (n = 35; 84%)Poor outcome (n = 7; 16%)P value
Age (years), median (IQR)11 (5-12.5)1.6 (1-8)0.02610 (2-13)1.7 (0.9-3)0.014
Male sex, n (%)14 (78)15 (62)0.28924 (68)5 (71)0.881
Evolution (days from initial symptoms), median (IQR)2.5 (2-10)7 (4-12)0.0364 (2-10)7 (7-15)0.043
Cardiac syndrome, n (%)
FM2 (8)10 (55)< 0.0017 (20)5 (71)< 0.001
CHF6 (25)4 (22)0.8348 (23)2 (28)0.746
Dysrhythmia3 (12)3 (16)0.7936 (17)0 (0)0.237
ACS-like13 (54)1 (5)0.00114 (40)0 (0)0.041
Viral prodromal, n (%)15 (62)14 (68)0.28923 (65)6 (85)0.296
Altered ECG, n (%)22 (91)17 (94)0.72932 (91)7 (100)0.421
CPR (mg/dL), median (IQR)4 (2-147)4 (3-125)0.4434 (2-144)33 (3-156)0.415
Troponin T (ng/mL), median (IQR)118 (5-580)91 (32-196)0.789103 (5-610)52 (32-177)0.447
NT-proBNP (pg/mL), median (IQR)291 (92-300)2700 (1955-4320)< 0.001300 (123-1955)5700 (2500-10321)0.002
LVEF (%), median (IQR)65 (58-66)34 (28-41)< 0.00159 (41-66)29 (27-31)< 0.001
LVDD Z score > 2, n (%)9 (37)17 (94)< 0.00119 (54)7 (100)0.023
Dyskinesia, n (%)11 (46)5 (27)0.23315 (43)1 (14)0.155
LGE in cMRI (n =21), n (%)12 (75)3 (60)0.51714 (70)1 (100)0.517
Positive Microbiology, n (%)12 (50)8 (44)0.30716 (45)4 (57)0.666
IQR: Interquartile range; CHF: Congestive heart failure; SCD: Sudden cardiac death; ACS: Acute coronary syndrome; FM: Fulminant myocarditis; CRP: C-reactive protein; LVEF: Left ventricle ejection fraction; LVDD: Left ventricle diastolic dysfunction; LGE: Late gadolinium enhancement; cMRI: Cardiac magnetic resonance imaging.
Table 4 Predictors for poor outcome at hospital discharge
VariableUnivariate analysis
Multivariate logistic regression1
OR (95%CI)P valueOR (95%CI)P value
Age < 2 yr8 (2-32)0.005
Evolution > 7 d3 (0.9-11)0.038
NT-proBNP > 5000 pg/mL15 (1.5-303)0.037
LVEF < 30%60 (3-347)0.00621 (2-456)0.027
1Multivariate logistic regression was performed only on risk factors in univariate analyses for early and late poor outcome (age < 2 yr, evolution > 7 d, N-terminal pro-brain natriuretic peptide > 5000, left ventricular ejection fraction < 30%). Odds ratios refer to the change in odds of poor early and late outcome when the predictor variables are presents. LVEF: Left ventricular ejection fraction; NT-proBNP: N-terminal pro-brain natriuretic peptide; OR: Odds ratio; CI: Confidence interval.
Table 5 Predictors for poor outcome at 1 yr from admission
VariableUnivariate analysis
Multivariate analysis1
OR (95%CI)P valueOR (95%CI)P value
Age < 2 yr6 (1.1-37)0.046
Evolution > 7 d10 (1.1-93)0.041
NT-proBNP > 5000 pg/mL13 (1.4-122)0.024
LVEF < 30%46 (4.4-392)0.0018 (0.56-135)0.041
1Multivariate logistic regression was performed only on risk factors in univariate analyses for early and late poor outcome (age < 2 yr, evolution > 7 d, N-terminal pro-brain natriuretic peptide > 5000, left ventricular ejection fraction < 30%). ORs refer to the change in odds of poor early and late outcome when the predictor variables are presents. LVEF: Left ventricular ejection fraction; NT-proBNP: N-terminal pro-brain natriuretic peptide; OR: Odds ratio; CI: Confidence interval.