2 At a glance commentary: Myocardial dysfunction is a major feature in the pathophysiology of septic shock. IL-6 has been identified as a key mediator of a negative inotropic state in meningococcal sepsis. In this study we demonstrate that the p38MAPK pathway is a central regulator in the negative inotropic activity of interleukin 6 and is highly dysregulated in meningococcal septic shock. Modulators of the p38MAPK pathway could have therapeutic potential for patients with cardiac dysfunction in meningococcal and other forms of septic shock. 2 Abstract: Objectives: Myocardial failure, leading to inotrope-unresponsive shock, is the predominant cause of death in meningococcal and other forms of septic shock. Pro-inflammatory cytokines released in septic shock are known to have myocardial depressant effects. We previously showed that Interleukin 6 (IL-6) is a major myocardial depressant factor in children with meningococcal septicaemia. In the current study, we aimed to investigate the mechanisms by which IL-6 induces myocardial failure in meningococcal sepsis, and to identify potential novel therapeutic targets. Design: Laboratory based study Setting: University hospital and laboratories Patients: Children with a clinical diagnosis of meningococcal septic shock Methods: We studied IL-6-induced signaling events, both in vitro using isolated rat ventricular cardiac myocytes as a model of myocardial contractility, and in whole blood from children with meningococcal sepsis. Measurements and Main results: We demonstrated involvement of JAK2, PI3K, Akt and p38MAPK in IL-6-induced negative inotropy in isolated cardiac myocytes. Inhibition of p38MAPK not only reversed IL-6-induced myocardial depression in both rat and human myocytes, but restored inotrope responsiveness. Cardiomyocytes transduced with dominant-negative p38MAPK showed no IL-6-induced myocardial depression. To investigate p38MAPK in vivo, we profiled global RNA expression patterns in peripheral blood of children with meningococcal septicaemia. Transcripts for genes mapping to the p38MAPK pathway showed significantly altered levels of abundance, with a high proportion of genes of this pathway affected. Conclusions: Our findings demonstrate an integral role of the p38MAPK pathway in IL-6-mediated cardiac contractile dysfunction and inotrope insensitivity. Dysregulation of the p38MAPK pathway in meningococcal septicemia suggests that this pathway may be an important target for novel therapies to 3 reverse myocardial dysfunction in patients with meningococcal septic shock who are not responsive to inotropic support. (273 words) 4 Introduction: Sepsis and septic shock remain major causes of morbidity and mortality worldwide, with reported mortality rates of 10-50% [1-4]. An important feature in the pathophysiology of septic shock is the development of progressive hemodynamic and cardiovascular instability and depressed myocardial contractility [5, 6]. Over the past three decades, intense efforts to develop immunomodulatory treatments for septic shock have target...