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J Pediatr Intensive Care 2022; 11(03): 215-220
DOI: 10.1055/s-0040-1722339
Original Article

Clinical Profile and Predictors of Outcome in Children with Acute Fulminant Myocarditis Receiving Intensive Care: A Single Center Experience

Muralidharan Jayashree 
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Manisha Patil
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Govindappa Benakatti
2   Department of Pediatric Intensive Care, NMC Royal Hospital, Abu Dhabi, United Arab Emirates
,
Manoj K. Rohit
3   Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Sunit Singhi
4   Department of Pediatrics, Medanta, the Medicity, Gurugram, India
,
Arun Bansal
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Arun Baranwal
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Karthi Nallasamy
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Suresh Kumar Angurana
1   Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
› Author Affiliations Funding None.
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Abstract

Acute myocarditis in children is associated with high morbidity and mortality, with limited data on intravenous immunoglobulin (IVIG) treatment and outcome. Our goal was to describe clinical, treatment profile, and predictors of outcome in children with acute fulminant myocarditis (AFM) receiving intensive care. Case records of 120 children with clinical diagnosis of acute myocarditis from January 2008 to December 2018 were analyzed retrospectively. AFM was seen in 89 (74.2%) children of which nearly two-thirds (54 [60.7%]) were hypotensive at admission. The median (interquartile range [IQR]) ejection fraction on echocardiography was 25 (18.5–36%). Eighty-two children (68.3%) received IVIG. Intensive care needs were mechanical ventilation (n = 71; 59.2%) and inotrope support (n = 89; 74.2%); median inotrope score being 30 (IQR: 20–55). Twenty-one children died (17.5%). Fever (p = 0.004), arrhythmia (p = 0.03), shock (p = 0.015), higher inotrope score (p = 0.0001), need for ventilation (p = 0.025), acidosis (p = 0.013), AKI (p = 0.0001), transaminitis (p = 0.0001), and multiorgan dysfunction (p = 0.0001) were associated with mortality. The mortality was significantly less in IVIG treated group (12.1 vs. 28.9%; p = 0.02). On multiple logistic regression, MODS (p = 0.002) was independent predictor of mortality while IVIG treatment (p = 0.004) was favorably associated with survival. AFM complicated by multiorgan dysfunction carried a poor prognosis. IVIG was associated with survival benefit.

Keywords

acute myocarditis - children - predictors - outcome - intravenous immunoglobulin


Publication History

Received: 01 September 2020

Accepted: 27 November 2020

Article published online:
25 January 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Rodriguez-Gonzalez M, Sanchez-Codez MI, Lubian-Gutierrez M, Castellano-Martinez A. Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: a retrospective study. World J Clin Cases 2019; 7 (05) 548-561
    CrossrefPubMedGoogle Scholar
  • 2 Feldman AM, McNamara D. Myocarditis. N Engl J Med 2000; 343 (19) 1388-1398
    CrossrefPubMedGoogle Scholar
  • 3 Felker GM, Hu W, Hare JM, Hruban RH, Baughman KL, Kasper EK. The spectrum of dilated cardiomyopathy. The Johns Hopkins experience with 1,278 patients. Medicine (Baltimore) 1999; 78 (04) 270-283
    CrossrefPubMedGoogle Scholar
  • 4 Soongswang J, Sangtawesin C, Sittiwangkul R. et al. Myocardial diseases in Thai children. J Med Assoc Thai 2002; 85 (Suppl. 02) S648-S657
    PubMedGoogle Scholar
  • 5 Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation 2006; 113 (04) 593-595
    CrossrefPubMedGoogle Scholar
  • 6 Ghelani SJ, Spaeder MC, Pastor W, Spurney CF, Klugman D. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes 2012; 5 (05) 622-627
    CrossrefPubMedGoogle Scholar
  • 7 Butts RJ, Boyle GJ, Deshpande SR. et al. Characteristics of clinically diagnosed pediatric myocarditis in a contemporary multi-center cohort. Pediatr Cardiol 2017; 38 (06) 1175-1182
    CrossrefPubMedGoogle Scholar
  • 8 Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6 (01) 2-8
    CrossrefPubMedGoogle Scholar
  • 9 Chong SL, Bautista D, Ang AS. Diagnosing paediatric myocarditis: what really matters. Emerg Med J 2015; 32 (02) 138-143
    CrossrefPubMedGoogle Scholar
  • 10 Klugman D, Berger JT, Sable CA, He J, Khandelwal SG, Slonim AD. Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol 2010; 31 (02) 222-228
    CrossrefPubMedGoogle Scholar
  • 11 Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics 2007; 120 (06) 1278-1285
    PubMedGoogle Scholar
  • 12 Checchia PA, Kulik TJ. Acute viral myocarditis: diagnosis. Pediatr Crit Care Med 2006; 7: S8-S11
    CrossrefPubMedGoogle Scholar
  • 13 Kern J, Modi R, Atalay MK, Kochilas LK. Clinical myocarditis masquerading as acute coronary syndrome. J Pediatr 2009; 154 (04) 612-615
    CrossrefPubMedGoogle Scholar
  • 14 Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24 (05) 495-497
    CrossrefPubMedGoogle Scholar
  • 15 Ichikawa R, Sumitomo N, Komori A. et al. The follow-up evaluation of electrocardiogram and arrhythmias in children with fulminant myocarditis. Circ J 2011; 75 (04) 932-938
    CrossrefPubMedGoogle Scholar
  • 16 Anderson BR, Silver ES, Richmond ME, Liberman L. Usefulness of arrhythmias as predictors of death and resource utilization in children with myocarditis. Am J Cardiol 2014; 114: 1400-1405
    CrossrefPubMedGoogle Scholar
  • 17 Liberman L, Anderson B, Silver ES, Singh R, Richmond ME. Incidence and characteristics of arrhythmias in pediatric patients with myocarditis: a multicenter study. Morgan Stanley Children's Hospital of New York -Presbyterian, Columbia University Medical Center, New York, USA. J Am Coll Cardiol 2014;63(12):
    PubMedGoogle Scholar
  • 18 Arslan A, Erdoğan İ, Varan B, Yılmaz M, Özin MB, Tokel NK. Reversible cardiomyopathy-tachycardiomyopathy in children. Turk J Pediatr 2019; 61 (04) 552-559
    CrossrefPubMedGoogle Scholar
  • 19 Moore JP, Patel PA, Shannon KM. et al. Predictors of myocardial recovery in pediatric tachycardia-induced cardiomyopathy. Heart Rhythm 2014; 11 (07) 1163-1169
    CrossrefPubMedGoogle Scholar
  • 20 Tunuguntla H, Jeewa A, Denfield SW. Acute myocarditis and pericarditis in children. Pediatr Rev 2019; 40 (01) 14-25
    CrossrefPubMedGoogle Scholar
  • 21 Chang YJ, Hsiao HJ, Hsia SH. et al. Analysis of clinical parameters and echocardiography as predictors of fatal pediatric myocarditis. PLoS One 2019; 14 (03) e0214087
    CrossrefPubMedGoogle Scholar
  • 22 Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics 2007; 120 (06) 1278-1285
    CrossrefPubMedGoogle Scholar
  • 23 Hsiao HJ, Hsia SH, Wu CT. et al. Clinical presentation of pediatric myocarditis in Taiwan. Pediatr Neonatol 2011; 52 (03) 135-139
    CrossrefPubMedGoogle Scholar
  • 24 Suthar D, Dodd DA, Godown J. Identifying non-invasive tools to distinguish acute myocarditis from dilated cardiomyopathy in children. Pediatr Cardiol 2018; 39 (06) 1134-1138
    CrossrefPubMedGoogle Scholar
  • 25 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 (01) 45-49
    CrossrefPubMedGoogle Scholar
  • 26 Drucker NA, Colan SD, Lewis AB. et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 1994; 89 (01) 252-257
    CrossrefPubMedGoogle Scholar
  • 27 Gagliardi MG, Bevilacqua M, Bassano C. et al. Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart 2004; 90 (10) 1167-1171
    CrossrefPubMedGoogle Scholar
  • 28 Huang X, Sun Y, Su G, Li Y, Shuai X. Intravenous immunoglobulin therapy for acute myocarditis in children and adults. Int Heart J 2019; 60 (02) 359-365
    CrossrefPubMedGoogle Scholar