Clinical manifestations and diagnosis of myocarditis in children
- Catherine K Allan, MD
Catherine K Allan, MD
- Assistant Professor of Pediatrics
- Harvard Medical School
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
- Section Editors
- John K Triedman, MD
John K Triedman, MD
- Section Editor — Pediatric Cardiology
- Professor of Pediatrics
- Harvard Medical School
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Myocarditis is a condition resulting from inflammation of the heart muscle. Myocellular damage results in myocardial dysfunction leading to heart failure. The clinical presentation can be acute or chronic. However, in contrast to adults, the majority of children with myocarditis present with acute or fulminant disease.
The incidence, clinical manifestations, and diagnosis of myocarditis in children are reviewed here. The treatment and prognosis of myocarditis are discussed separately. (See "Treatment and prognosis of myocarditis in children".)
The causes of myocarditis are diverse and include infectious, toxic, and autoimmune etiologies (table 1). Infectious etiologies, particularly viral, are most common in children. The most common causes of viral myocarditis are enterovirus (coxsackie group B), adenovirus, parvovirus B19, Epstein-Barr virus, cytomegalovirus, and human herpes 6 (HHV-6) . Cases may be sporadic or epidemic, and have seasonal and geographical variation [2,3]. Rarely, pediatric myocarditis may be associated with autoimmune disorders and drug hypersensitivity. The etiology and pathogenesis of myocarditis are presented in greater detail separately. (See "Etiology and pathogenesis of myocarditis".)
It is difficult to estimate the incidence of pediatric myocarditis because there is no sensitive and specific diagnostic test for myocarditis. As a result, the diagnosis often is not confirmed. In one retrospective study from a single tertiary pediatric Canadian center, the estimated prevalence of myocarditis presenting to their emergency department was 0.5 cases per 10,000 visits . Other reports suggest an annual incidence of 1 per 100,000 children .
In addition, affected patients may be asymptomatic and found to have evidence of myocarditis after unexpected death [6,7], including infants who were diagnosed with sudden infant death syndrome [8-11]. (See "Sudden cardiac arrest and death in children", section on 'Etiology'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Canter CE, Simpson KE. Diagnosis and treatment of myocarditis in children in the current era. Circulation 2014; 129:115.
- Mounts AW, Amr S, Jamshidi R, et al. A cluster of fulminant myocarditis cases in children, Baltimore, Maryland, 1997. Pediatr Cardiol 2001; 22:34.
- Strikas RA, Anderson LJ, Parker RA. Temporal and geographic patterns of isolates of nonpolio enterovirus in the United States, 1970-1983. J Infect Dis 1986; 153:346.
- Freedman SB, Haladyn JK, Floh A, et al. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics 2007; 120:1278.
- Levine MC, Klugman D, Teach SJ. Update on myocarditis in children. Curr Opin Pediatr 2010; 22:278.
- Weber MA, Ashworth MT, Risdon RA, et al. Clinicopathological features of paediatric deaths due to myocarditis: an autopsy series. Arch Dis Child 2008; 93:594.
- Doolan A, Langlois N, Semsarian C. Causes of sudden cardiac death in young Australians. Med J Aust 2004; 180:110.
- deSa DJ. Isolated myocarditis as a cause of sudden death in the first year of life. Forensic Sci Int 1986; 30:113.
- Råsten-Almqvist P, Eksborg S, Rajs J. Myocarditis and sudden infant death syndrome. APMIS 2002; 110:469.
- Shimizu C, Rambaud C, Cheron G, et al. Molecular identification of viruses in sudden infant death associated with myocarditis and pericarditis. Pediatr Infect Dis J 1995; 14:584.
- Dettmeyer R, Baasner A, Schlamann M, et al. Coxsackie B3 myocarditis in 4 cases of suspected sudden infant death syndrome: diagnosis by immunohistochemical and molecular-pathologic investigations. Pathol Res Pract 2002; 198:689.
- Ghelani SJ, Spaeder MC, Pastor W, et al. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes 2012; 5:622.
- Bonadio WA, Losek JD. Infants with myocarditis presenting with severe respiratory distress and shock. Pediatr Emerg Care 1987; 3:110.
- Press S, Lipkind RS. Acute myocarditis in infants. Initial presentation. Clin Pediatr (Phila) 1990; 29:73.
- Greenwood RD, Nadas AS, Fyler DC. The clinical course of primary myocardial disease in infants and children. Am Heart J 1976; 92:549.
- Towbin JA. Cardiomyopathies. In: Pediatric Cardiovascular Medicine, Moller JH (Ed), Churchill Livingstone, 2000. p.758.
- Durani Y, Egan M, Baffa J, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009; 27:942.
- Wang JN, Tsai YC, Lee WL, et al. Complete atrioventricular block following myocarditis in children. Pediatr Cardiol 2002; 23:518.
- Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24:495.
- Miyake CY, Teele SA, Chen L, et al. In-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. Am J Cardiol 2014; 113:535.
- Ramachandra G, Shields L, Brown K, Ramnarayan P. The challenges of prompt identification and resuscitation in children with acute fulminant myocarditis: case series and review of the literature. J Paediatr Child Health 2010; 46:579.
- Caforio AL, Pankuweit S, Arbustini E, et al. 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.
- Snyder M. Pediatric viral myocarditis. Air Med J 2003; 22:6.
- Friedman RA, Kearney DL, Moak JP, et al. Persistence of ventricular arrhythmia after resolution of occult myocarditis in children and young adults. J Am Coll Cardiol 1994; 24:780.
- Balaji S, Wiles HB, Sens MA, Gillette PC. Immunosuppressive treatment for myocarditis and borderline myocarditis in children with ventricular ectopic rhythm. Br Heart J 1994; 72:354.
- Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care 2012; 28:1173.
- 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.
- Soongswang J, Durongpisitkul K, Ratanarapee S, et al. Cardiac troponin T: its role in the diagnosis of clinically suspected acute myocarditis and chronic dilated cardiomyopathy in children. Pediatr Cardiol 2002; 23:531.
- Koulouri S, Acherman RJ, Wong PC, et al. Utility of B-type natriuretic peptide in differentiating congestive heart failure from lung disease in pediatric patients with respiratory distress. Pediatr Cardiol 2004; 25:341.
- Molina KM, Garcia X, Denfield SW, et al. Parvovirus B19 myocarditis causes significant morbidity and mortality in children. Pediatr Cardiol 2013; 34:390.
- Kane DA, Fulton DR, Saleeb S, et al. Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology. Congenit Heart Dis 2010; 5:366.
- Foerster SR, Canter CE, Cinar A, et al. Ventricular remodeling and survival are more favorable for myocarditis than for idiopathic dilated cardiomyopathy in childhood: an outcomes study from the Pediatric Cardiomyopathy Registry. Circ Heart Fail 2010; 3:689.
- Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J 2008; 29:2073.
- Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1987; 1:3.
- Webber SA, Boyle GJ, Jaffe R, et al. Role of right ventricular endomyocardial biopsy in infants and children with suspected or possible myocarditis. Br Heart J 1994; 72:360.
- Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995; 333:269.
- Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 1994; 89:252.
- Chow LH, Radio SJ, Sears TD, McManus BM. Insensitivity of right ventricular endomyocardial biopsy in the diagnosis of myocarditis. J Am Coll Cardiol 1989; 14:915.
- Bowles NE, Ni J, Kearney DL, et al. Detection of viruses in myocardial tissues by polymerase chain reaction. evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol 2003; 42:466.
- Brighenti M, Donti A, Giulia Gagliardi M, et al. Endomyocardial biopsy safety and clinical yield in pediatric myocarditis: An Italian perspective. Catheter Cardiovasc Interv 2016; 87:762.
- Pophal SG, Sigfusson G, Booth KL, et al. Complications of endomyocardial biopsy in children. J Am Coll Cardiol 1999; 34:2105.
- Cowley CG, Lozier JS, Orsmond GS, Shaddy RE. Safety of endomyocardial biopsy in children. Cardiol Young 2003; 13:404.
- Daly KP, Marshall AC, Vincent JA, et al. Endomyocardial biopsy and selective coronary angiography are low-risk procedures in pediatric heart transplant recipients: results of a multicenter experience. J Heart Lung Transplant 2012; 31:398.
- Zhorne D, Petit CJ, Ing FF, et al. A 25-year experience of endomyocardial biopsy safety in infants. Catheter Cardiovasc Interv 2013; 82:797.
- Cooper LT, Baughman KL, Feldman AM, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation 2007; 116:2216.
- Richardson P, McKenna W, Bristow M, et al. Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of cardiomyopathies. Circulation 1996; 93:841.
- Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation 2006; 113:1807.
- Elliott P, Andersson B, Arbustini E, et al. Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2008; 29:270.
- Gagliardi MG, Bevilacqua M, Di Renzi P, et al. Usefulness of magnetic resonance imaging for diagnosis of acute myocarditis in infants and children, and comparison with endomyocardial biopsy. Am J Cardiol 1991; 68:1089.
- Costello JM, Alexander ME, Greco KM, et al. Lyme carditis in children: presentation, predictive factors, and clinical course. Pediatrics 2009; 123:e835.
- CLINICAL MANIFESTATIONS
- - Fulminant myocarditis
- Physical examination
- Initial testing
- - Electrocardiogram
- - Cardiac biomarkers
- - Chest radiograph
- - Echocardiogram
- - Other studies
- Clinical diagnosis
- Endomyocardial biopsy
- - Dallas criteria
- Poor sensitivity
- - Other tests
- - Complications
- - Societal statements
- Magnetic resonance imaging
- Our approach
- FURTHER DIAGNOSTIC EVALUATION
- DIFFERENTIAL DIAGNOSIS
- Acute heart failure
- Respiratory distress
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS