Skip to main content
SpringerLink
Log in

Myocarditis

  • Chapter
  • First Online:
Cardiac Pathology

  • 1468 Accesses

Abstract

Myocarditis/inflammatory cardiomyopathy is defined as inflammatory lesion affecting heart muscle with leucocytic cell infiltration and non-ischaemic degeneration and/or necrosis of myocytes. The disease incidence is unknown, but is most often related to infections, with viruses being the most common cause. Auto-immunity either alone, or as a sequel to a viral myocarditis, also has a role. Myocardial inflammation may also occur in relation to drugs and toxins. The patterns of these different myocarditic processes are described and the pathophysiology is discussed.

Many cases cannot be verified on endomyocardial biopsy and a multi-disciplinary approach involving clinicians, immunologists and pathologists together with serological and molecular tests is required.

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

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. 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;29:270–6.

    Article  PubMed  Google Scholar 

  2. Shauer A, Gotsman I, Keren A, et al. Acute viral myocarditis: current concepts in diagnosis and treatment. Isr Med Assoc J. 2013;15:180–5.

    PubMed  Google Scholar 

  3. Saphir O. Myocarditis, a general review with an analysis of 240 cases. Arch Pathol. 1941;32:1000–7.

    Google Scholar 

  4. Global Burden of Disease Study 2013 Collaborators. Global, regional and national incidence, prevalence and years lived with disability for 301 chronic disease and injuries in 188 countries, 1990-2013: a systematic analysis for the global Burden of disease Study 2013. Lancet. 2015;386:743–800.

    Article  PubMed Central  Google Scholar 

  5. Caforio A, Pankuweit E, 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;34:2636–48.

    Article  PubMed  Google Scholar 

  6. Eckart R, Scoville E, Campbell C, et al. Sudden death in young adults: a 25 year review of autopsies in military recruits. Ann Intern Med. 2004;141:829–34.

    Article  PubMed  Google Scholar 

  7. Gravanis M, Sternby N. Incidence of myocarditis. Arch Pathol Lab Med. 1991;115:390–2.

    CAS  PubMed  Google Scholar 

  8. Passarino G, Burlo P, Ciccone G, et al. Prevalence of myocarditis at autopsy in Turin Italy. Arch Pathol Lab Med. 1997;121:619–22.

    CAS  PubMed  Google Scholar 

  9. Karjalainen K, Heikkila J. Incidence of three presentations of the acute myocarditis in young men in military service: a 20 year experience. Eur Heart J. 1999;20:1020–5.

    Article  Google Scholar 

  10. Chow L, Radio S, Sear T, McManus B. Insensitivity of right ventricular endomyocardial biopsy in the diagnosis of myocarditis. J Am Coll Cardiol. 1989;14:915–20.

    Article  CAS  PubMed  Google Scholar 

  11. Elamm C, Fairweather D, Cooper L. Pathogenesis and diagnosis of myocarditis. Heart. 2012;98:835–40.

    Article  CAS  PubMed  Google Scholar 

  12. Mason J, O’Connell A, Herskowitz A, et al. A clinical trial of immunosuppressive therapy in myocarditis. N Engl J Med. 1995;333:269–75.

    Article  CAS  PubMed  Google Scholar 

  13. Baughman K. Clinical presentations of myocarditis. Heart Fail Clin. 2005;1:363–76.

    Article  PubMed  Google Scholar 

  14. Kindermann I, Barth C, Mahfoud F, et al. Update on myocarditis. J Am Coll Cardiol. 2012;59:779–92.

    Article  PubMed  Google Scholar 

  15. Magnani J, Dec G. Myocarditis: current trends in diagnosis and treatment. Circulation. 2006;113:876–90.

    Article  PubMed  Google Scholar 

  16. Aretz HT. Myocarditis: the Dallas criteria. Hum Pathol. 1987;18:619–24.

    Article  CAS  PubMed  Google Scholar 

  17. Edwards W, Holmes D, Reeder G. Diagnosis of active lymphocytic myocarditis by endomyocardial biopsy: quantitative criteria for light microscopy. Mayo Clin Proc. 1982;57:419–25.

    CAS  PubMed  Google Scholar 

  18. Tazelaar H, Billingham M. Myocardial lymphocytes: fact, fancy or myocarditis. Am J Cardiovasc Pathol. 1987;1:47–50.

    CAS  PubMed  Google Scholar 

  19. Linder J, Cassling R, Rogler W, et al. Immunohistochemical characterisation of lymphocytes in uninflamed ventricular myocardium. Arch Pathol Lab Med. 1985;109:917–20.

    CAS  PubMed  Google Scholar 

  20. Schnitt S, Ciano P, Scoen F. Quantification of lymphocytes in endomyocardial biopsies: use and limitations of antibodies to leucocyte common antigen. Hum Pathol. 1987;18:796–800.

    Article  CAS  PubMed  Google Scholar 

  21. Bowles N, Richardson P, Olsen E, Archard L. Detection of coxsackie-b-virus specific RNA sequences in myocardial biopsy samples from patients with myocarditis and dilated cardiomyopathy. Lancet. 1986;i:1120–3.

    Article  Google Scholar 

  22. Bowles N, Ni J, Kearney D, 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;42:466–72.

    Article  PubMed  Google Scholar 

  23. Why H, Meany B, Richardson P, et al. Clinical and prognostic significance of detection of enteroviral RNA in the myocardium of patients with myocarditis or dilated cardiomyopathy. Circulation. 1994;89:2582–9.

    Article  CAS  PubMed  Google Scholar 

  24. Bock CT, Klinel K, Kandolf R. Human parvovirus B19- associated myocarditis. N Engl J Med. 2010;362:1248–9.

    Article  CAS  PubMed  Google Scholar 

  25. Murry C, Jerome K, Reichenbach D. Fatal parvovirus myocarditis in a 5-year old girl. Hum Pathol. 2001;32:342–5.

    Article  CAS  PubMed  Google Scholar 

  26. Verdonschot J, Hazebroek M, Merken J, et al. Relevance of cardiac parvovirus B19 in myocarditis and dilated cardiomyopathy: review of the literature. Eur J Heart Fail. 2016;18:1430–1.

    Article  PubMed  Google Scholar 

  27. Yoshikawa T, Ihira M, Suzuki K, et al. Fatal acute myocarditis in an infant with human herpesvirus 6 infection. J Clin Pathol. 2001;54:792–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Stewart G, Lopez-Molina A, Gottumukkala R, et al. Myocardial parvovirus B19 persistence: lack of association with clinicopathologic phenotype in adults with heart failure. Circ Heart Fail. 2011;4:71–8.

    Article  PubMed  Google Scholar 

  29. Figulla HR. Transformation of myocarditis and inflammatory cardiomyopathy to idiopathic dilated cardiomyopathy: fact and fiction. Med Microbiol Immunol. 2004;193:61–4.

    Article  PubMed  Google Scholar 

  30. Kuhl U, Pauschinger M, Noutsias M, et al. High prevalence of viral genomes and multiple viral infections in the myocardium of adults with “idiopathic” left ventricular dysfunction. Circulation. 2005;111:887–93.

    Article  PubMed  Google Scholar 

  31. D’Ambrosio A, Patti G, Manzoli A, et al. The fate of acute myocarditis between spontaneous improvement and evolution to dilated cardiomyopathy: a review. Heart. 2001;85:499–504.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Woudstra L, Juffermans J, van Rossum A, Niessen H, Krijnen P. Infectious myocarditis: the role of the cardiac vasculature. Heart Fail Rev. 2018;23:583–95.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Zanone M, Favaro E, Conaldi P, et al. Persistent infection of human microvascular endothelial cells by coxsackie B viruses induces increased expression of adhesion molecules. J Immunol. 2003;171:438–46.

    Article  CAS  PubMed  Google Scholar 

  34. Ino T, Kishiro M, Okubo M, et al. Late persistent expression of ICAM-1 and VCAM-1 on myocardial tissue in children with lymphocytic myocarditis. Cardiovasc Res. 1997;34:323–8.

    Article  CAS  PubMed  Google Scholar 

  35. Li W, Yu S, Zhao H. Expression of MHC-I and MHC-II antigens in endomyocardial biopsies from patients with viral myocarditis and cardiomyopathy. Chin Med J (Engl). 1995;108:809–11.

    CAS  Google Scholar 

  36. Kumar A, Perdomo M, Kantele A, et al. Granzyme B mediated function of Parvovirus B19 specific CD4(+) T cells. Clin Trans Immunol. 2015;4:e39.

    Article  CAS  Google Scholar 

  37. Esfandiarei M, McManus B. Molecular biology and pathogenesis of viral myocarditis. Annu Rev Pathol. 2008;3:127–55.

    Article  CAS  PubMed  Google Scholar 

  38. Heymans S, Riksson U, Lehtonen J, Cooper L. The quest for new approaches to inflammatory cardiomyopathy. J Am Coll Cardiol. 2016;68:2346–64.

    Article  Google Scholar 

  39. Nicholson F, Ajetunmobi J, Li M, et al. Molecular detection and serotypic analysis of enterovirus RNA in archival specimens from patients with acute myocarditis. Br Heart J. 1995;74:522–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Halapas A, Pissimissis N, Lembessis P, et al. Molecular diagnosis of the viral component in cardiomyopathies: pathophysiological, clinical and therapeutic implications. Expert Opin Ther Targets. 2008;12:821–36.

    Article  CAS  PubMed  Google Scholar 

  41. Tomko R, Xu R, Philipson L. HCAR and MCAR: the human and mouse cellular receptors for subgroup C adenoviruses and group B coxsackieviruses. Proc Natl Acad Sci U S A. 1998;94:3362.

    Google Scholar 

  42. Bergelson J, Krithivas A, Celi L, et al. The murine CAR homolog is a receptor for coxsackie B viruses and adenoviruses. J Virol. 1998;72:415–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Carthy C, Granville D, Watson K, et al. Caspase activation and cleavage of substrates following coxsackie B3 induced cytopathic effects in HeLa cells. J Virol. 1998;72:7669–75.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. Harris K, Coyne C. Death waits for no man - does it wait for a virus? How Enteroviruses induce and control cell death. Cytokine Growth Factor Rev. 2014;25:587–96.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Yuan J, Liu Z, Lim T, et al. CXCL10 inhibits viral replication through recruitment of natural killer cells in coxsackie B3 induced myocarditis. Circ Res. 2009;104:628–38.

    Article  CAS  PubMed  Google Scholar 

  46. Altara R, Mallat Z, Booz G, Zouein F. The CXCL10/CXCR3 axis and cardiac inflammation: implications for immunotherapy to treat infectious and non-infectious diseases of the heart. J Immunol Res. 2016;2016:3496368.

    Article  CAS  Google Scholar 

  47. Deonarain R, Cerullo D, Fuse K, et al. Protective role for interferon-β in coxsackievirus B3 infection. Circulation. 2004;110:3540–3.

    Article  CAS  PubMed  Google Scholar 

  48. Epelmann S, Liu P, Mann D. Role of innate and adaptive immune mechanisms in cardiac injury. Nat Rev Immunol. 2015;15:117–29.

    Article  CAS  Google Scholar 

  49. Jenke A, Wilk S, Poller W, et al. Adiponectin protects against Toll-like receptor 4 mediated cardiac inflammation and injury. Cardiovasc Res. 2013;99:422–31.

    Article  CAS  PubMed  Google Scholar 

  50. Yang Y, Lv J, Jiang S, et al. The emerging role of Toll-like receptor 4 in myocardial inflammation. Cell Death Dis. 2016;7:e2234.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Noutsias M, Rohde M, Goldner K, et al. Expression of functional T-cell markers and T-cell receptor V beta repertoire in endomyocardial biopsies from patients presenting with acute myocarditis and dilated cardiomyopathy. Eur J Heart Fail. 2011;13:611–8.

    Article  CAS  PubMed  Google Scholar 

  52. Cihakova D, Rose N. Pathogenesis of myocarditis and dilated cardiomyopathy. Adv Immunol. 2008;99:95–114.

    Article  CAS  PubMed  Google Scholar 

  53. Woodruff J, Woodruff J. Involvement of T lymphocytes in the pathogenesis of coxsackie B3 heart disease. J Immunol. 1974;113:1726–34.

    CAS  PubMed  Google Scholar 

  54. Opavsky M, Penninger J, Atken K, et al. Susceptibility to myocarditis is dependent on the response of αβ T lymphocytes to coxsackieviral infection. Circ Res. 1999;85:551–8.

    Article  CAS  PubMed  Google Scholar 

  55. Matsui Y, Inobe M, Okamoto H, et al. Blockade of T cell co-stimulatory signals using adenoviral vectors prevents both the induction and the progression of experimental autoimmune myocarditis. J Mol Cell Cardiol. 2002;34:279–95.

    Article  CAS  PubMed  Google Scholar 

  56. Li L, Li L, Xiao L, Shangguan J. Progranulin ameliorates coxsackievirus-B3-induced viral myocarditis by downregulating Th1 and Th17 cells. Exp Cell Res. 2018;367:241–50.

    Article  CAS  PubMed  Google Scholar 

  57. Cheng H, Xi Y, Chi X, Wu Y, Liu G. Fenofibrate treatment of rats with experimental autoimmune myocarditis by alleviating Treg/Th17 disorder. Central Eur J Immunol. 2016;1:64–70.

    Article  CAS  Google Scholar 

  58. Yuan J, Yu M, Lin Q, et al. Neutralisation of IL-17 inhibits the production of anti-ANT autoantibodies in CVB-3 induced acute viral myocarditis. Int Immunopharmacol. 2010;10:272–6.

    Article  CAS  PubMed  Google Scholar 

  59. Kraj P, Ignatowicz L. The mechanisms shaping the repertoire of CD4+ FoxP3+ regulatory T cells. Immunology. 2017;153:290–6.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  60. An B, Liu X, Li G, Yuan H. Interleukin 37 ameliorates coxsackievirus B3 induced viral myocarditis by modulating the Th17/regulatory T cell immune response. J Cardiovasc Pharmacol. 2017;69:305–13.

    Article  CAS  PubMed  Google Scholar 

  61. Simpson K, Cunningham M, Lee C, et al. Autoimmunity against the heart and cardiac myosin in children with myocarditis. J Card Fail. 2016;22:520–8.

    Article  CAS  PubMed  Google Scholar 

  62. Dorner A, Kallwellis-Opara A, Pauschinger M, Kuhl U, Schuktheiss H. Cardiac autoantibodies in viral myocarditis. Heart Fail Clin. 2005;1:333–43.

    Article  PubMed  Google Scholar 

  63. Caforio A, Tona F, Bpttaro S, et al. Clinical implications of anti-heart antibodies in myocarditis and dilated cardiomyopathy. Autoimmunity. 2008;41:36–45.

    Google Scholar 

  64. Latva-Horvela J, Kyto V, Saraste A, et al. Development of troponin autoantibodies in experimental coxsackie B3 myocarditis. J Clin Invest. 2009;39:457–62.

    Google Scholar 

  65. Rose N, Beisel A, Herskowitz A, et al. Cardiac myosin and autoimmune myocarditis. Ciba Found Symp. 1987;127:3–24.

    Google Scholar 

  66. Muller J, Wallukat G, Schimke I. Autoantibodies directed against the β1-adrenergic receptor in patients with dilated cardiomyopathy. J Am Coll Cardiol. 2017;70:808–9.

    Article  PubMed  Google Scholar 

  67. Wang Z, Liao Y, Dong J, Li S, Wang J, Fu M. Clinical significance and pathogenic role of ant-cardiac myosin antibody in dilated cardiomyopathy. Chin Med J (Engl). 2003;116:499–502.

    Google Scholar 

  68. Caforio A, Grazzini M, Mann J, et al. Identification of alpha- and beta-cardiac myosin heavy chain isoforms as major autoantigens in dilated cardiomyopathy. Circulation. 1992;85:1734–42.

    Article  CAS  PubMed  Google Scholar 

  69. Latif N, Baker C, Dunn M, Rose M, Brady P, Yacoub M. Frequency and specificity of anti-heart antibodies in patients with dilated cardiomyopathy detected using SDS-PAGE and western blotting. J Am Coll Cardiol. 1993;22:1378–84.

    Article  CAS  PubMed  Google Scholar 

  70. Neu N, Rose N, Beisel K, Herskowitz G, Gurri-Glass G, Craig S. Cardiac myosin induces myocarditis in genetically predisposed mice. J Immunol. 1987;139:3630–6.

    CAS  PubMed  Google Scholar 

  71. Yuan H, Liao Y, Wang Z, et al. Prevention of myosin induced autoimmune myocarditis in mice by anti-L3 T4 monoclonal antibody. Can J Physiol Pharmacol. 2003;81:84–8.

    Article  CAS  PubMed  Google Scholar 

  72. Chen P, Baldeviano G, Ligons D, et al. Susceptibility to autoimmune myocarditis is associated with intrinsic differences in CD4(+) T cells. Clin Exp Immunol. 2012;169:79–88.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  73. Hwang S, Song K, Lesourne R, et al. Reduced TCR signalling potential impairs negative selection but does not result in autoimmune disease. J Exp Med. 2012;209:1781–95.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. Fairweather D, Frisancho-Kiss S, Rose N. Viruses as adjuvants for autoimmunity: evidence from Coxsackievirus induced myocarditis. Rev Med Virol. 2001;15:17–27.

    Article  CAS  Google Scholar 

  75. Chapman N, Kim S. Persistent coxsackievirus infection: enterovirus persistence in chronic myocarditis and dilated cardiomyopathy. Curr Top Microbiol Immunol. 2008;323:275–92.

    CAS  PubMed  Google Scholar 

  76. Bowles N, Richardson P, Olsen E, Archard L. Detection of coxsackie-B-Virus specific RNA sequences in myocardial biopsy samples from patients with myocarditis and dilated cardiomyopathy. Lancet. 1986;1:1120–3.

    Article  CAS  PubMed  Google Scholar 

  77. Orinius E. The late cardiac prognosis after Coxsackie-B infection. Acta Med Scand. 1968;183:235–7.

    Article  CAS  PubMed  Google Scholar 

  78. McWhorter J, LeRoy E. Pericardial disease in scleroderma (systemic sclerosis). Am J Med. 1974;57:566–75.

    Article  PubMed  Google Scholar 

  79. Morguet A, Sandrock D, Stille-Siegener M, Figulla H. Indium-111-antimyosin Fab imaging to demonstrate myocardial involvement in systemic lupus erythematosus. J Nucl Med. 1995;36:1432–5.

    CAS  PubMed  Google Scholar 

  80. Rossi M, Ramos S. Pathogenesis of chronic Chagas’ myocarditis: an overview. Cardiovasc Pathol. 1996;5:197–202.

    Article  CAS  PubMed  Google Scholar 

  81. Kumar R, Tandon R. Rheumatic fever and rheumatic heart disease: the last 50 years. Indian J Med Res. 2013;13:643–58.

    Google Scholar 

  82. Gross L, Ehrlich J. Studies on the myocardial Aschoff body. Am J Pathol. 1934;10:467.

    CAS  PubMed  PubMed Central  Google Scholar 

  83. Kuchynka P, Palecek T, Masek M, et al. Current diagnostic and therapeutic aspects of eosinophilic myocarditis. Biomed Res Int. 2016;2016:2828583. https://doi.org/10.1155/2016/2829583.

    Article  CAS  Google Scholar 

  84. Cooper LT Jr. Myocarditis. N Engl J Med. 2008;360:1526–38.

    Article  Google Scholar 

  85. Baandrup U. Eosinophilic myocarditis. Herz. 2012;37:849–53.

    Article  CAS  PubMed  Google Scholar 

  86. Greco A, Rizzo M, De Virgilio A, et al. Churg-Strauss syndrome. Autoimmun Rev. 2015;14:341–8.

    Article  CAS  PubMed  Google Scholar 

  87. Ogbogu P, Bochner B, Butterfield J, et al. Hypereosinophilic syndrome: a multicentre retrospective analysis of clinical characteristics and response to therapy. J Allergy Clin Immunol. 2009;124:1319–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  88. Seguela P, Iriart X, Acar P, Montasudon M, Roudaut R, Thambo J. Eosinophilic cardiac disease: molecular, clinical and imaging aspects. Arch Cardiovasc Dis. 2015;108:258–68.

    Article  PubMed  Google Scholar 

  89. Baily G. Parasitic infections of the heart. J Infect. 1998;37:2–4.

    Article  CAS  PubMed  Google Scholar 

  90. Cooper L Jr. Giant cell and granulomatous myocarditis. Heart Fail Clin. 2005;1:431–7.

    Article  PubMed  Google Scholar 

  91. Blauwet L, Cooper L. Idiopathic giant cell myocarditis and cardiac sarcoidosis. Heart Fail Rev. 2013;18:733–46.

    Article  PubMed  Google Scholar 

  92. Cooper L, Berry G, Shabetai R. Idiopathic giant cell myocarditis - natural history and treatment. N Engl J Med. 1997;336:1860–6.

    Article  PubMed  Google Scholar 

  93. Sekhri V, Sanal S, Delorenzo L, Aronow W, Maguire G. Cardiac sarcoidosis: a comprehensive review. Arch Med Sci. 2011;7:546–54.

    Article  PubMed  PubMed Central  Google Scholar 

  94. Silverman K, Hutchins G, Bulkley B. Cardiac sarcoid. A clinicopathological evaluation of 84 unselected cases with systemic sarcoidosis. Circulation. 1978;58:1204–11.

    Article  CAS  PubMed  Google Scholar 

  95. Baughman K. Diagnosis of myocarditis – death of Dallas criteria. Circulation. 2006;113:593–5.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Histopathology, Royal Papworth Hospital, Cambridge, UK

    Martin J. Goddard

Authors
  1. Martin J. Goddard
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Martin J. Goddard .

Editor information

Editors and Affiliations

  1. Sheffield Teaching Hospitals, Royal Hallamshire Hospital Sheffield Teaching Hospitals, Sheffield, South Yorkshire, UK

    S. Kim Suvarna

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Goddard, M.J. (2019). Myocarditis. In: Suvarna, S. (eds) Cardiac Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-24560-3_8

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-24560-3_8

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-24559-7

  • Online ISBN: 978-3-030-24560-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation