SpringerLink
Log in

Parvovirus B19 myocarditis in children: a diagnostic and therapeutic approach

  • Original Article
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

Abstract

Parvovirus B19 is one of the most frequent causes of pediatric myocarditis, associating high mortality rates or need for cardiac transplantation. The aim of this study is to describe the clinical course of Parvovirus B19 myocarditis in children with emphasis on the role of endomyocardial biopsy and cardiac magnetic resonance, and the use of an innovative therapeutic strategy. Eleven patients and 12 episodes of polymerase chain reaction (PCR)-confirmed Parvovirus B19 myocarditis were prospectively collected for 14 years. Diagnosis was confirmed either histopathologically or by magnetic resonance. A life-threatening clinical presentation is described, similar to previous series, but with 83.3% overall survival without transplantation. We also present a case of recurrent myocarditis, which is extraordinarily rare. Electrocardiographic patterns presented chiefly peaked p waves, low QRS voltages, and negative T waves on inferior or lateral leads. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance could be a useful diagnostic tool. A good concordance between myocardial and blood PCRs was observed. Seven patients received treatment with corticosteroids and beta interferon and all underwent a significant cardiac function improvement.

Conclusion: A severe clinical presentation is reported, similar to previous reports but with better outcomes. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance may be used. Both blood and myocardium PCR can be used in children to establish the microbiological etiology. Steroids with IFNß could be a useful therapeutic option, although further multicenter studies are needed to confirm these results.

What is Known:

• Parvovirus B19 is one of the most frequent causes of myocarditis in children. It is associated with a fulminant clinical presentation.

• Endomyocardial biopsy is the gold standard diagnostic test but it is an invasive procedure.

What is New:

• Myocarditis may recur in pediatrics, even it is extraordinarily rare.

• IFNβ with steroids may be a useful therapeutic option to improve the outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Availability of data and material

Yes.

Abbreviations

MRI:

Magnetic resonance imaging

ECG:

Electrocardiogram

ECMO:

Extracorporeal membrane oxygenation

IFNß:

Beta interferon

IQR:

Interquartile range

LV:

Left ventricle

PCR:

Polymerase chain reaction

RV:

Right ventricle

TAPSE:

Tricuspid annular plane systolic excursion

References

  1. Ammirati E, Frigerio M, Adler ED et al (2020) Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document. Circ Heart Fail 13(11):e007405. https://doi.org/10.1161/CIRCHEARTFAILURE.120.007405

    Article  PubMed  PubMed Central  Google Scholar 

  2. Molina KM, Garcia X, Denfield SW et al (2013) Parvovirus B19 myocarditis cause significant morbidity and mortality in children. Pediatr Cardiol 34(2):390–397. https://doi.org/10.1007/s00246-012-0468-4

    Article  PubMed  Google Scholar 

  3. Sinagra G, Anzini M, Pereira NL et al (2016) Myocarditis in clinical practice. Mayo Clin Proc 91(9):1256–1266. https://doi.org/10.1016/j.mayocp.2016.05.013

    Article  PubMed  Google Scholar 

  4. Caforio AL, Pankuweit S, Arbustini E et al (2013) 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 34(33):2636–48. https://doi.org/10.1093/eurheartj/eht210

  5. Zhorne D, Petit CJ, Ing FF et al (2013) A 25-year experience of endomyocardial biopsy safety in infants. Catheter Cardiovascular Inter 82(2):797–801. https://doi.org/10.1002/ccd.24802

    Article  Google Scholar 

  6. Mills KI, Vincent JA, Zuckerman WA et al (2016) Is endomyocardial biopsy a safe and useful procedure in children with suspected cardiomyopathy? Pediatr Cardiol 37(7):1200–1210. https://doi.org/10.1007/s00246-016-1416-5

    Article  PubMed  Google Scholar 

  7. Friedrich MG, Sechtem U, Schulz-Menger J et al (2009) International Consensus Group on Cardiovascular Magnetic Resonance in Myocarditis. Cardiovascular magnetic resonance in myocarditis: a JACC White Paper. J Am Coll Cardiol 53(17):1475–87. https://doi.org/10.1016/j.jacc.2009.02.007

  8. Verdonschot J, Hazebroek M, Merken J et al (2016) Relevance of cardiac parvovirus B19 in myocarditis and dilated cardiomyopathy: review of the literature. Eur J Heart Fail 18(12):1430–1441. https://doi.org/10.1002/ejhf.665

    Article  PubMed  Google Scholar 

  9. Vigneswaran TV, Brown JR, Breuer J et al (2016) Parvovirus B19 myocarditis in children: an observational study. Arch Dis Child 101(2):177–180. https://doi.org/10.1136/archdischild-2014-308080

    Article  PubMed  Google Scholar 

  10. Minocha PH, Better D, Singh RK et al (2021) Recurrence of acute myocarditis associated with receipt of the mRNA coronavirus disease 2019 (COVID-19) vaccine in a male adolescent. J Pediatr 238:321–323. https://doi.org/10.1016/j.jpeds.2021.06.035

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Floyd A, Lal A, Molina K et al (2018) When lightning strikes twice in pediatrics: case report and review of recurrent myocarditis. Pediatrics 141(3):e20164096. https://doi.org/10.1542/peds.2016-4096

    Article  PubMed  Google Scholar 

  12. Simpson KE, Storch GA, Lee CK et al (2016) High frequency of detection by PCR of viral nucleic acid in the blood of infants presenting with clinical myocarditis. Pediatr Cardiol 37(2):399–404. https://doi.org/10.1007/s00246-015-1290-6

    Article  PubMed  Google Scholar 

  13. Kuethe F, Lindner J, Matschke K et al (2009) Prevalence of parvovirus B19 and human bocavirus DNA in the heart of patients with no evidence of dilated cardiomyopathy or myocarditis. Clin Infect Dis 49(11):1660–1666. https://doi.org/10.1086/648074

    Article  PubMed  Google Scholar 

  14. Bock CT, Klingel K, Kandolf R (2010) Human parvovirus B19-associated myocarditis. N Engl J Med 362(13):1248–1249. https://doi.org/10.1056/NEJMc0911362

    Article  CAS  PubMed  Google Scholar 

  15. Banka P, Robinson JD, Uppu SC;, et al (2015) Cardiovascular magnetic resonance techniques and findings in children with myocarditis: a multicenter retrospective study. J Cardiovasc Magn Reson 17:96. https://doi.org/10.1186/s12968-015-0201-6

    Article  PubMed  PubMed Central  Google Scholar 

  16. Francone M, Chimenti C, Galea N et al (2014) CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis. JACC Cardiovasc Imaging 7(3):254–263. https://doi.org/10.1016/j.jcmg.2013.10.011

    Article  PubMed  Google Scholar 

  17. Howard A, Hasan A, Brownlee J et al (2020) Pediatric myocarditis protocol: an algorithm for early identification and management with retrospective analysis for validation. Pediatr Cardiol 41(2):316–326. https://doi.org/10.1007/s00246-019-02258-1

    Article  PubMed  Google Scholar 

  18. Gagliardi MG, Bevilacqua M, Bassano C et al (2004) Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart 90(10):1167–1171. https://doi.org/10.1136/hrt.2003.026641

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kuhl U, Pauschinger M, Schwimmbeck PL et al (2003) Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation 107(22):2793–2798. https://doi.org/10.1161/01.CIR.0000072766.67150.51

    Article  CAS  PubMed  Google Scholar 

  20. Kühl U, Pauschinger M, Bock T et al (2003) Parvovirus B19 infection mimicking acute myocardial infarction. Circulation 108(8):945–950. https://doi.org/10.1161/01.CIR.0000085168.02782.2C

    Article  CAS  PubMed  Google Scholar 

  21. Schultheiss HP, Piper C, Sowade O et al (2016) Betaferon in chronic viral myocarditis (BICC) trial: effects of interferon-beta treatment in patients with chronic viral cardiomyopathy. Clin Res Cardiol 105(9):763–773. https://doi.org/10.1007/s00392-016-0986-9

    Article  CAS  PubMed  Google Scholar 

  22. Gran F, Martínez-Villar M, Soler-Palacín P et al (2016) Immunosuppressive therapy and interferon-1β in acute myocarditis. Rev Esp Cardiol 69(11):1106–1107. https://doi.org/10.1016/j.rec.2016.05.015

    Article  PubMed  Google Scholar 

  23. Mahrholdt H, Wagner A, Deluigi CC et al (2006) Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation 114(15):1581–1590. https://doi.org/10.1161/CIRCULATIONAHA.105.606509

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Pediatric Cardiology, Vall d’Hebron Hospital Campus, Passeig de la Vall d’Hebron 119-129, 08035, Barcelona, Spain

    Roger Esmel-Vilomara, Paola Dolader & Ferran Gran

  2. Pediatric Cardiology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain

    Roger Esmel-Vilomara

  3. Pediatric Critical Care, Vall d’Hebron Hospital Campus, Barcelona, Spain

    Jaume Izquierdo-Blasco & Joan Balcells

  4. Pediatric Cardiology, Hospital Virgen de La Arrixaca, Murcia, Spain

    Moisés Sorlí & Fuensanta Escudero

  5. Pediatric Cardiology, Hospital Universitario Araba, Vitoria-Gasteiz, Spain

    Elena Vera

Authors
  1. Roger Esmel-Vilomara
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paola Dolader
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jaume Izquierdo-Blasco
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Joan Balcells
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Moisés Sorlí
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fuensanta Escudero
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Elena Vera
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ferran Gran
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the conception and design of the work. Data collection, analysis, and interpretation were performed by Roger Esmel-Vilomara and Ferran Gran. The first draft was written by Roger Esmel-Vilomara. The draft was read and approved by all the authors.

Corresponding author

Correspondence to Roger Esmel-Vilomara.

Ethics declarations

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Vall d’Hebron Hospital Campus.

Consent to participate

Not applicable.

Consent for publication

Informed consent for publication was obtained.

Conflict of interest

The authors declare no competing interests.

Additional information

Communicated by Roger Esmel-Vilomara

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Esmel-Vilomara, R., Dolader, P., Izquierdo-Blasco, J. et al. Parvovirus B19 myocarditis in children: a diagnostic and therapeutic approach. Eur J Pediatr 181, 2045–2053 (2022). https://doi.org/10.1007/s00431-022-04406-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-022-04406-x

Keywords

Search

Navigation