ORIGINAL PAPER
The value of chosen diagnostic tools in evaluating myocarditis in children and adolescents
Submission date: 2018-07-11
Final revision date: 2018-09-28
Acceptance date: 2018-09-28
Publication date: 2018-10-30
Pediatr Pol 2018;93(5):389-395
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Myocarditis is an inflammatory disease of the myocardium. Paediatric myocarditis is frequently overlooked due a misleading presentation when characteristic symptoms are lacking.
Aim of the study:
The aim of our study was to assess the clinical presentation of myocarditis in children, and the sensitivity and usefulness of chosen tests for diagnosing this disease.
Material and methods:
A retrospective chart review of paediatric patients with myocarditis was performed, where electrocardiography (ECG) and biomarker test results (leucocytes number, creatine kinase – CK, creatine kinase myocardial band – CKMB, troponin I, C-reactive protein – CRP, N-terminal precursor of natriuretic peptide type B – NT-proBNP) at admission and discharge were analysed along with echocardiography and cardiac magnetic resonance (CMR).
Results:
Thirty-one cases were gathered, of which the majority presented with cardiac (90.3%) or respiratory (61.3%) symptoms. In most cases, normal or only slightly lowered ejection fraction (EF) was observed (mean 62.9%, 95% CI 60.6–65.1%). ECG changes, cardiac troponin I, and CMR proved the most sensitive tests with respective sensitivities of 96.8% (95% CI 83.3–99.9%), 96.7% (95% CI 82.78–99.9%), and 100% (95% CI 83.2–100%). At discharge, levels of inflammatory and myocardial necrosis marker concentrations were significantly lower, and ejection fraction was significantly improved compared to ejection fraction at admission. CMR changes (i.e. signs of inflammation, delayed enhancement) were usually located in the inferolateral basal and mid-ventricular segments of the left ventricle. CRP, CK, and CKMB at admission correlated with the length of hospital stay.
Conclusions:
Cardiac troponin, ECG changes, and cardiac magnetic resonance are highly sensitive tests for myocarditis in children. The initial values of biomarkers (concentration of CRP and activities of CK and CKMB) correlate with the length of hospital stay. Myocarditis in children is most commonly located in the inferolateral wall of the left ventricle.
Myocarditis is an inflammatory disease of the myocardium. Paediatric myocarditis is frequently overlooked due a misleading presentation when characteristic symptoms are lacking.
Aim of the study:
The aim of our study was to assess the clinical presentation of myocarditis in children, and the sensitivity and usefulness of chosen tests for diagnosing this disease.
Material and methods:
A retrospective chart review of paediatric patients with myocarditis was performed, where electrocardiography (ECG) and biomarker test results (leucocytes number, creatine kinase – CK, creatine kinase myocardial band – CKMB, troponin I, C-reactive protein – CRP, N-terminal precursor of natriuretic peptide type B – NT-proBNP) at admission and discharge were analysed along with echocardiography and cardiac magnetic resonance (CMR).
Results:
Thirty-one cases were gathered, of which the majority presented with cardiac (90.3%) or respiratory (61.3%) symptoms. In most cases, normal or only slightly lowered ejection fraction (EF) was observed (mean 62.9%, 95% CI 60.6–65.1%). ECG changes, cardiac troponin I, and CMR proved the most sensitive tests with respective sensitivities of 96.8% (95% CI 83.3–99.9%), 96.7% (95% CI 82.78–99.9%), and 100% (95% CI 83.2–100%). At discharge, levels of inflammatory and myocardial necrosis marker concentrations were significantly lower, and ejection fraction was significantly improved compared to ejection fraction at admission. CMR changes (i.e. signs of inflammation, delayed enhancement) were usually located in the inferolateral basal and mid-ventricular segments of the left ventricle. CRP, CK, and CKMB at admission correlated with the length of hospital stay.
Conclusions:
Cardiac troponin, ECG changes, and cardiac magnetic resonance are highly sensitive tests for myocarditis in children. The initial values of biomarkers (concentration of CRP and activities of CK and CKMB) correlate with the length of hospital stay. Myocarditis in children is most commonly located in the inferolateral wall of the left ventricle.
REFERENCES (36)
1.
Suthar D, Dodd DA, Godown J. Identifying Non-invasive Tools to Distinguish Acute Myocarditis from Dilated Cardiomyopathy in Children. Pediatr Cardiol 2018; 39: 1134-1138.
2.
Caforio AL, Pankuweit S, Arbustini E, et al. European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013; 34: 2636-48, 2648a-2648d.
3.
Dominguez F, Kühl U, Pieske B, et al. Update on Myocarditis and Inflammatory Cardiomyopathy: Reemergence of Endomyocardial Biopsy. Rev Esp Cardiol (Engl Ed) 2016; 69: 178-187.
4.
Freedman SB, Haladyn JK, Floch A, et al. Pediatric Myocarditis: Emergency Department Clinical Findings and Diagnostic Evaluation. Pediatrics 2007; 120: 1278-1285.
5.
Dettmeyer R, Baasner A, Schlamann M, et al. Role of virus-induced myocardial affections in sudden infant death syndrome: a prospective postmortem study. Pediatr Res 2004; 55: 947-952.
6.
Wisotzkey BL, Soriano BD, Albers EL, et al. Diagnostic role of strain imaging in atypical myocarditis by echocardiography and cardiac MRI. Pediatr Radiol 2018; 48: 835-884.
7.
Merchant Q, Haque A, Hasan BS. Management of acute myocarditis in children. J Pak Med Assoc 2013; 63: 803-811.
8.
Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper. J Am Coll Cardiol 2009; 53: 1475-1487.
9.
Baccouche H, Mahrholdt H, Meinhardt G, et al. Diagnostic synergy of non-invasive cardiovascular magnetic resonance and invasive endomyocardial biopsy in troponin-positive patients without coronary artery disease. Eur Heart J 2009; 30: 2869-2879.
10.
Kułaga Z, Litwin M, Grajda A, et al. Distribution of blood pressure in school-aged children and adolescents reference population. Stand Med, Pediatr 2010; 7: 853-864.
11.
Ostrowska-Nawarycz L, Nawarycz T. Normy ciśnienia tętniczego u dzieci i młodzieży – doświadczenia łódzkie. Nadciśn Tętn 2007; 11: 138-150.
12.
Bazett HC. An analysis of the time-relations of electrocardiograms. Heart 1920; 7: 353-370.
13.
Talmon G, Fink DL, Horowitz Y, et al. The prevalence of subclinical myocarditis among young with acute viral infection. Harefuah 2015; 154: 641-645, 676, 675.
14.
Chun JH, Kim TH, Han MY, et al. Analysis of clinical characteristics and causes of chest pain in children and adolescents. Korean J Pediatr 2015; 58: 440-445.
15.
Mahrholdt H, Wagner A, Deluigi CC, et al. Presentation, Patterns of Myocardial Damage, and Clinical Course of Viral Myocarditis. Circulation 2006; 114: 1581-1590.
16.
Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001; 108: 793-797.
17.
Canter CE, Simpson KE. Diagnosis and Treatment of Myocarditis in Children in the Current Era. Circulation 2014; 129: 115-128.
18.
Kułaga Z, Różdżyńska A, Palczewska I, et al. Percentile charts of height, body mass and body mass index in children and adolescents in Poland – results of the OLAF study. Stand Med, Pediatr 2010; 7: 690-700.
19.
Mahfoud F, Gärtner B, Kindermann M, et al. Virus serology in patients with suspected myocarditis: utility or futility? Eur Heart J 2011; 32: 897-903.
20.
Kindermann I, Barth C, Mahfoud F, et al. Update on Myocarditis. J Am Coll Cardiol 2012; 59: 779-792.
21.
Romero-Gómez MP, Guereta L, Pareja-Grande J, et al. Myocarditis Caused by Human Parainfluenza Virus in an Immunocompetent Child Initially Associated with 2009 Influenza A (H1N1) Virus. J Clin Microbiol 2011; 49: 2072-2073.
22.
Chiu SN, Wang JK, Wu MH, et al. Taipei Pediatric Cardiology Working Group. Cardiac conduction disturbance detected in a pediatric population. J Pediatr 2008; 152: 85-89.
23.
Yoshinaga M, Iwamoto M, Horigome H, et al. Standard Values and Characteristics of Electrocardiographic Findings in Children and Adolescents. Circ J 2018; 82: 831-839.
24.
Tse G, Yeo JM, Chan YW, et al. What Is the Arrhythmic Substrate in Viral Myocarditis? Insights from Clinical and Animal Studies. Front Physiol 2016; 7: 308.
25.
Hung Y, Lin WH, Lin CS, et al. The Prognostic Role of QTc Interval in Acute Myocarditis. Acta Cardiol Sin 2016; 32: 223-230.
26.
Freedman SB, Haladyn JK, Thull-Freedman J, et al. Cardiac Troponins in Pediatric Myocarditis: In Reply. Pediatrics 2008; 121: 864.
27.
Soongswang J, Durongpisitkul K, Nana A, et al. Cardiac troponin T: a marker in the diagnosis of acute myocarditis in children. Pediatr Cardiol 2005; 26: 45-49.
28.
Lauer B, Niederau C, Kühl U, et al. Cardiac troponin T in patients with clinically suspected myocarditis. J Am Coll Cardiol 1997; 30: 1354-1359.
29.
Kelley WE, Januzzi JL, Christenson RH. Increases of Cardiac Troponin in Conditions other than Acute Coronary Syndrome and Heart Failure. Clin Chem 2009; 55: 2098-2112.
30.
Eisenberg MA, Greene-Hopkins I, Alexander ME, et al. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care 2012; 28: 1173-1178.
31.
Al-Biltagi M, Issa M, Hagar HA, et al. Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis. Acta Paediatr 2010; 99: 1510-1516.
32.
Jeserich M, Konstantinides S, Pavlik G, et al. Non-invasive imaging in the diagnosis of acute viral myocarditis, Clin Res Cardiol 2009; 98: 753-763.
33.
Schultz JC, Hilliard AA, Cooper LS, et al. Diagnosis and Treatment of Viral Myocarditis. Mayo Clin Proc 2009; 84: 1001-1009.
34.
Yelgec NS, Dymarkowski S, GanameJ, et al. Value of MRI in patients with a clinical suspicion of acute myocarditis. Eur Radiol 2007; 17: 2211-2217.
35.
Liu G, Yang X, Su Y, et al. Cardiovascular magnetic resonance imaging findings in children with myocarditis. Chin Med J (Engl) 2014; 127: 3700-3705.
36.
Sachdeva S, Song X, Dham N, et al. Analysis of clinical parameters and cardiac magnetic resonance imaging as predictors of outcome in pediatric myocarditis. Am J Cardiol 2015;115: 499-504.
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