Clinical course, viral etiology, and the diagnostic workup for patients with suspected myocarditis: a single-center prospective study

Shimaa S Khidr, Mohamed Ahmed El-Mokhtar, Shery Refaat Asaad, Helal F Hetta, Mona Hussein Abdel-Rahim, Amr Ahmed Aly Youssef, Ayman K M Hassan, Shimaa S Khidr, Mohamed Ahmed El-Mokhtar, Shery Refaat Asaad, Helal F Hetta, Mona Hussein Abdel-Rahim, Amr Ahmed Aly Youssef, Ayman K M Hassan

Abstract

Background: Myocarditis is a highly heterogeneous disorder with a challenging diagnostic work-up. We aimed to focus on the possible diagnostic workup for this condition in settings where endomyocardial biopsy as a gold standard is not always feasible, detect the etiologic cardiotropic viruses in our locality, and follow the clinical course in patients admitted with clinically suspected myocarditis.

Methods: This is a prospective observational study. We recruited patients with clinically suspected myocarditis presenting at a university hospital from October 1st, 2020 until March 31st, 2021. All Patients had a diagnostic coronary angiography and were included only if they had a non-obstructive coronary artery disease. All patients also had cardiac magnetic resonance imaging (CMR) with contrast. Sera were obtained from all suspected patients for detection of antibodies against viruses using enzyme-linked immunosorbent assay, and viral genomes using polymerase chain reaction (PCR), and reverse transcription-PCR. Endomyocardial biopsy was done for patients with a typical CMR picture of myocarditis.

Results: Out of 2163 patients presenting to the hospital within the 6 months, only 51 met the inclusion criteria. Males represented 73%, with a mean age of 39 ± 16 years. CMR showed an ischemic pattern in 4 patients and thus they were excluded. We classified patients into two categories based on CMR results: group A (CMR-positive myocarditis), 12 patients (25.5%), and group B (CMR-negative myocarditis), 35 (74.5%) patients. On serological analysis, 66% of patients (n = 31/47) showed antibodies against the common cardiotropic viruses. Parvovirus B19 IgM in 22 patients (47%) and coxsackievirus IgM in 16 (34%) were the most observed etiologies. Regarding the outcome, 42.5% of patients recovered left ventricular ejection fraction and three patients died at 6 months' clinical follow-up.

Conclusion: Patients with Clinically suspected myocarditis represented 2.2% of total hospital admissions in 6 months. CMR is only a good positive test for the diagnosis of acute myocarditis. Parvovirus B19 and coxsackievirus were the most common pathogens in our locality.

Trial registration: Clinical trial registration no., NCT04312490; first registration: 18/03/2020. First recruited case 01/10/2020. URL: https://register.

Clinicaltrials: gov/prs/app/action/SelectProtocol?sid=S0009O3D&selectaction=Edit&uid=U0002DVP&ts=2&cx=9zdfin .

Keywords: Cardiac magnetic resonance imaging; Cardiotropic virus; ELISA; Endomyocardial biopsy; Myocarditis; Polymerase chain reaction; Clinically suspected myocarditis.

Conflict of interest statement

The authors had no conflict of interest to declare.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flow chart of the study groups with clinical follow-up at 6 months
Fig. 2
Fig. 2
CMR, T2 weighted image in short axis view at the level of the papillary muscles, showing areas of regional increase in the signal intensity (myocardium and the covering pericardium) (arrow), indicative of edema and acute inflammation, from one of our cases
Fig. 3
Fig. 3
CMR, T1 based phase sensitive inversion recovery images, in vertical long axis view and short axis view for the same patient in Fig. 1, 10–20 min after 0.2 mg/kg gadolinium-based dye intravenous injection, showing mid myocardial–sub-pericardial patches of enhancement (arrows), a pattern typical for myocarditis

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