Cardiogenic shock due to citomegalovirus myocarditis: successful clinical treatment

Abstract

Objective: Cytomegalovirus (CMV) systemic disease and myocarditis in healthy persons is infrequently reported in the literature, although in increasing numbers in recent years. The importance of the recognition of the syndrome that usually has an initial picture of a mononucleosis like infection in an otherwise healthy person, is the available therapeutic agent, ganciclovir, that can cure the infectious disease.Methods: We analyzed the clinical result of pulsotherapy with steroids in a patient with CMV myocarditis after 7 days of etiological treatment, with ganciclovir, intravenous vasodilators, and the conventional treatment for congestive heart failure.Results: The clinical condition of the patient improved accordingly to the better function of the left ventricle, and the ganciclovir was kept for 21 days, most of it in an out patient basis. The patient was dismissed from the hospital, with normal myocardial function.Conclusion: Potentially curable forms of myocarditis, like M pneumoniae and CMV, for example, can have an initial disproportionate aggression to the myocardium, by the acute inflammatory reaction, that can by itself make worse the damage to the LV function. In our opinion, the blockade of this process by pulsotherapy with steroids can help in the treatment of these patients. We understand that the different scenario of immunosuppressive treatments for the possible auto immunity of the more chronic forms of the presumably post viral cardiomyopathy has been in dispute in the literature, and has stolen the focus from the truly acute cases.Descriptors: Myocarditis. Cardiogenic shock. Ganciclovir. Pulse therapy, drug. ResumoObjetivo: Doença sistêmica por citomegalovírus (CMV) com miocardite em pessoas saudáveis é raramente referida na literatura, apesar de em maior número em anos recentes. A importância do reconhecimento da síndrome, que usualmente tem um quadro inicial "mononucleosis like" em uma pessoa sadia é a disponibilidade do agente terapêutico ganciclovir, que pode curar a infecção.Métodos: Nós analisamos o resultado da pulsoterapia com esteróides em um paciente com miocardite por CMV, após 7 dias de tratamento etiológico com ganciclovir, vasodilatadores intravenosos e o tratamento convencional para insuficiência cardíaca congestiva.Resultados: A condição clínica do paciente melhorou com a melhor função do ventrículo esquerdo e o ganciclovir foi mantido por 21 dias após alta hospitalar. A função miocárdica retornou ao normal.Conclusão: Formas curáveis de miocardites como M pneumonia e CMV, por exemplo, podem ter uma agressão grave ao miocárdio por uma ação inflamatória que pode piorar a função cardíaca. Em nossa opinião, o bloqueio deste processo pela pulsoterapia com esteróides pode auxiliar no tratamento destes pacientes. Entendemos que existe um cenário diferente de tratamento com imunossupressores para possível agressão auto-imune das formas mais crônicas de cardiomiopatias dilatadas e isso está em disputa na literatura, talvez mudando o foco dos casos realmente agudos.Descritores: M...

Fulminant Cytomegalovirus Myocarditis in an Immunocompetent Host: Resolution with Oral Valganciclovir

“…1,4,8,11 If the CMV infection is associated with pericarditis, patients might also report pleuritic chest pain and manifest pericardial friction rub on auscultation, diffuse ST elevations on ECG, and pericardial effusion on echocardiography. 6,7,9,10,13 Classically, a prolonged viral prodrome is typical before the development of cardiac symptoms, as seen in our patient.…”

“…1,3,[5][6][7]9,10,12,13 In the presented case and in 2 previously reported cases with documented severe left ventricular dysfunction, the antiviral therapy led to a complete resolution of symptoms. 8,11 On the other hand, 4 of 16 patients with CMV myocarditis who had multiorgan involvement did not receive antiviral therapy and died. 1,4 Even though half of the cases of CMV infection in an immunocompetent host are mild and self-limiting (with complete recovery), the benefits of valganciclovir therapy might outweigh the risks when one considers the high mortality rate in patients with fulminant myocarditis, severe myocardial dysfunction, and multiorgan involvement.…”

“…In contrast, CMV myocarditis and pericarditis in an immunocompetent host are extremely rare entities: few cases have been reported to date. [3][4][5][6][7][8][9][10][11][12][13] It is quite possible that the true number of CMV myocarditis cases is underreported, because most cases are self limiting and underdiagnosed. …”

DCMP as a Clinical Syndrome: Results of Nosological Diagnostics With Myocardial Biopsy and Differentiated Treatment in Virus-Positive and Virus-Negative Patients

“…Безусловно, при назначении ИСТ должно учиты-ваться наличие активной вирусной инфекции. Однако в целом ряде других работ была показана успешность применения ИСТ у вирус-позитивных больных в соче-тании с противовирусным лечением: у детей с острым, а также с хроническим миокардитом и синдромом ДКМП, при котором выраженный эффект ИСТ был получен независимо от персистенции вирусов в мио-карде при отсутствии улучшения в группе контроля [26,27]; у взрослых с тяжелым вирусным миокардитом [28,29]. Маастрихтский алгоритм подразумевает при одновременном выявлении вирусного генома в мио-карде и антикардиальных антител проведение проти-вовирусного лечения с последующей ИСТ [30]; анало-гичных принципов придерживается группа Andréoletti L, et al [31].…”

Emerging pharmacologic targets and treatments for myocarditis

“…Following five days of treatment the LVEF improved from 10% to 50% and the patient went on to make a full recovery. Other successful case reports for the treatment of viral myocarditis include ganciclovir to treat Cytomegalovirus-myocarditis (Baumgratz, et al, 2010), ribavirin with IVIG for the treatment of human parainfluenza virus type 2-myocarditis (Kalimuddin, et al, 2013), acyclovir with IVIG for the treatment of parvovirus-B19-myocarditis , and Artesunate for the treatment of human herpesvirus 6B pediatric myocarditis (Hakacova, et al, 2013) (Table 1). Due to the rarity of persistent viral myocarditis induced by a given virus, large multi-center randomized controlled trials to properly investigate antiviral therapy will be…”