Correspondence

Fulminant Coxsackieviral Myocarditis

N Engl J Med 2001; 345:379August 2, 2001

Article

To the Editor:

Enteroviruses are the most common agents of myocarditis and have been implicated in the pathogenesis of dilated cardiomyopathy. There are still discrepancies in our knowledge of the association of enteroviruses and myocardial disease, partially due to a lack of data on detection of viral antigen on viral culture of tissue.1 For the treatment of fulminant myocarditis, aggressive hemodynamic support is warranted because of the excellent long-term prognosis of patients.2

A 16-year-old girl was admitted with anterior chest pain of one day's duration. Two weeks earlier, she had had influenza-like symptoms. The patient had a positive troponin T result and an elevated level of creatinine phosphokinase. A coronary angiogram showed no thrombus and no clinically significant stenosis, and spasm was not induced with ergonovine. The next day, shock and pulmonary edema developed. Her ejection fraction was less than 20 percent. Despite the use of an intraaortic balloon pump for four hours, her shock and pulmonary edema progressed. Mechanical circulatory support was started with a left ventricular assist device (Bio-pump, Medtronic Bio-Medicus). After 126 hours of support with the left ventricular assist device, left-ventricular-wall motion was restored and her ejection fraction was 79 percent on echocardiography. The left ventricular assist device was removed after 10 days. She was discharged after 23 days without any symptoms of heart failure.

Immunohistochemical analysis of the left atrial appendage that underwent biopsy at the time of insertion of the left ventricular assist device showed the enteroviral capsid protein VP1 (primary antibody, Novocastra Laboratories)2 over the entire left atrial wall (Figure 1Figure 1Detection of the Enteroviral Capsid Protein VP1 in the Left Atrial Appendage by Immunohistochemical Analysis.). Her serum neutralized coxsackievirus B3 (H3 variant, Woodruff strain) in a neutralization test performed with the use of a horse antibody against coxsackievirus B3 (American Type Culture Collection, V030-501-560) as a positive control.3 The titer of neutralizing antibody in her serum at 21 days was more than four times the titer at 2 days.

Our study of this patient with fulminant coxsackieviral myocarditis provides further evidence of an association of enterovirus and myocardial disease, as demonstrated by the results of immunohistochemical analysis of tissue and changes in the titer of serum neutralizing antibody.

In-Whan Seong, M.D., Ph.D.
Chungnam National University Hospital, TaeJon, 301-721, Korea

Seong-Choon Choe, M.D., Ph.D.
Eun-Seok Jeon, M.D., Ph.D.
SoonChunHyang University Hospital, Bucheon, 420-853, Korea
esjeon@schbc.ac.kr

3 References

1. 1

   Li Y, Bourlet T, Andreoletti L, et al. Enteroviral capsid protein VP1 is present in myocardial tissues from some patients with myocarditis or dilated cardiomyopathy. Circulation 2000;101:231-234
   Web of Science | Medline

2. 2

   McCarthy RE III, Boehmer JP, Hruban RH, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 2000;342:690-695
   Full Text | Web of Science | Medline

3. 3

   Knowlton KU, Jeon E-S, Berkley N, Wessely R, Huber S. A mutation in the puff region of VP2 attenuates the myocarditic phenotype of an infectious cDNA of the Woodruff variant of coxsackievirus B3. J Virol 1996;70:7811-7818
   Web of Science | Medline

Citing Articles (11)

Citing Articles

1. 1

   Li Yue-Chun, Ge Li-Sha, Yang Peng-Lin, Tang Ji-Fei, Lin Jia-Feng, Chen Peng, Guan Xue-qiang. (2010) Carvedilol treatment ameliorates acute coxsackievirus B3-induced myocarditis associated with oxidative stress reduction. European Journal of Pharmacology 640:1-3, 112-116
   CrossRef

2. 2

   Mirae Lee, Ghee-Young Kwon, June-Soo Kim, Eun-Seok Jeon. (2010) Giant Cell Myocarditis Associated With Coxsackievirus Infection. Journal of the American College of Cardiology 56:10, e19
   CrossRef

3. 3

   Hyun Jung Kim, Gyeong-Hee Yoo, Hong Ryang Kil. (2010) Clinical outcome of acute myocarditis in children according to treatment modalities. Korean Journal of Pediatrics 53:7, 745
   CrossRef

4. 4

   Boris Bigalke, Peter L. Schwimmbeck, Christian S. Haas, Stephan Lindemann. (2009) Effect of interleukin-15 on the course of myocarditis in Coxsackievirus B3-infected BALB/c mice. Canadian Journal of Cardiology 25:7, e248-e254
   CrossRef

5. 5

   Kirk U. Knowlton, Byung-Kwan Lim. (2009) Viral Myocarditis. Journal of the American College of Cardiology 53:14, 1227-1228
   CrossRef

6. 6

   Jin-Ho Choi, Eun Seok Jun. (2008) Treatment of Medically Intractable End-Stage Heart Failure. Journal of the Korean Medical Association 51:4, 306
   CrossRef

7. 7

   Li Yue-Chun, Ge Li-Sha, Ren Jiang-Hua, Yang Peng-Lin, Lin Jia-Feng, Tang Ji-Fei, Chen Peng, Yang Zhan-Qiu. (2008) Protective Effects of Carvedilol in Murine Model With the Coxsackievirus B3-Induced Viral Myocarditis. Journal of Cardiovascular Pharmacology 51:1, 92-98
   CrossRef

8. 8

   Jong-Mook Kim, Byung-Kwan Lim, Seong-Hyun Ho, Soo-Hyeon Yun, Jae-Ok Shin, Eun-Min Park, Duk-Kyung Kim, Sunyoung Kim, Eun-Seok Jeon. (2006) TNFR-Fc fusion protein expressed by in vivo electroporation improves survival rates and myocardial injury in coxsackievirus induced murine myocarditis. Biochemical and Biophysical Research Communications 344:3, 765-771
   CrossRef

9. 9

   Zhen Liu, Ji Yuan, Bobby Yanagawa, Dexin Qiu, Bruce M McManus, Decheng Yang. (2005) Coxsackievirus-induced myocarditis: new trends in treatment. Expert Review of Anti-infective Therapy 3:4, 641-650
   CrossRef

10. 10

    Jeonghyun Ahn, Chul Hyun Joo, Ilsun Seo, DongHou Kim, Yoo Kyum Kim, Heuiran Lee. (2005) All CVB serotypes and clinical isolates induce irreversible cytopathic effects in primary cardiomyocytes. Journal of Medical Virology 75:2, 290-294
    CrossRef

11. 11

    Carsten Tschöpe, Dirk Westermann, Paul Steendijk, Michael Noutsias, Susanne Rutschow, Anneke Weitz, Peter Lothar Schwimmbeck, Heinz-Peter Schultheiss, Matthias Pauschinger. (2004) Hemodynamic characterization of left ventricular function in experimental coxsackieviral myocarditis: effects of carvedilol and metoprolol. European Journal of Pharmacology 491:2-3, 173-179
    CrossRef