Identifying Non-invasive Tools to Distinguish Acute Myocarditis from Dilated Cardiomyopathy in Children

Original Article

Abstract

There is often a diagnostic dilemma in pediatric patients presenting with depressed ventricular function, as myocarditis and dilated cardiomyopathy (DCM) of other etiologies can appear very similar. Accurate identification is critical to guide treatment and to provide families with the most accurate expectation of long-term outcomes. The objective of this study was to identify patterns of clinical presentation and to assess non-invasive measures to differentiate patients with acute myocarditis from other forms of DCM. We identified all children (< 18 years) from our institution with a diagnosis of idiopathic DCM or myocarditis based on endomyocardial biopsy or explant pathology (1996–2015). Characteristics at the time of presentation were compared between patients with a definite diagnosis of myocarditis and those with idiopathic DCM. Data collected included clinical and laboratory data, radiography, echocardiography, and cardiac catheterization data. A total of 58 patients were included in the study; 46 (79%) with idiopathic DCM and 12 (21%) with acute myocarditis. Findings favoring a diagnosis of myocarditis included a history of fever (58 vs. 15%, p = 0.002), arrhythmia (17 vs. 0%, p = 0.003), higher degree of cardiac enzyme elevation, absence of left ventricular dilation (42 vs. 7%, p = 0.002), segmental wall motion abnormalities (58 vs. 13%, p = 0.001), lower left ventricular dimension z-score (3.7 vs. 5.2, p = 0.031), and less severe depression of left ventricular systolic function. There are notable differences between patients with myocarditis and other forms of DCM that can be detected non-invasively at the time of presentation without the need for endomyocardial biopsy. These data suggest that it may be possible to develop a predictive model to differentiate myocarditis from other forms of DCM using non-invasive measures.

Keywords

Myocarditis Dilated cardiomyopathy Brain natriuretic peptide (BNP) Pediatric Echocardiography Left ventricular dysfunction 

Notes

Compliance with Ethical Standards

Conflict of interest

None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This retrospective study was approved by the Vanderbilt University Institutional Review Board.

Informed Consent

Informed consent was not obtained from all individual participants included in the study as waiver of request for consent was obtained from the Vanderbilt University Institutional Review Board as this was a retrospective review study.

References

  1. 1.
    Towbin JA et al (2006) Incidence, causes, and outcomes of dilated cardiomyopathy in children. JAMA 296(15):1867–1876CrossRefPubMedGoogle Scholar
  2. 2.
    Everitt MD et al (2014) Recovery of echocardiographic function in children with idiopathic dilated cardiomyopathy: results from the pediatric cardiomyopathy registry. J Am Coll Cardiol 63(14):1405–1413CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Wilkinson JD et al (2010) The Pediatric Cardiomyopathy Registry and heart failure: key results from the first 15 years. Heart Fail Clin 6(4):401–413CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lipshultz SE et al (2003) The incidence of pediatric cardiomyopathy in two regions of the United States. N Engl J Med 348(17):1647–1655CrossRefPubMedGoogle Scholar
  5. 5.
    Nugent AW et al (2001) Clinical, electrocardiographic, and histologic correlations in children with dilated cardiomyopathy. J Heart Lung Transpl 20(11):1152–1157CrossRefGoogle Scholar
  6. 6.
    Lee KJ et al (1999) Clinical outcomes of acute myocarditis in childhood. Heart 82(2):226–233CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    English RF et al (2004) Outcomes for children with acute myocarditis. Cardiol Young 14(5):488–493CrossRefPubMedGoogle Scholar
  8. 8.
    Canter CE, Simpson KE (2014) Diagnosis and treatment of myocarditis in children in the current era. Circulation 129(1):115–128CrossRefPubMedGoogle Scholar
  9. 9.
    Richardson P et al (1996) Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the definition and classification of cardiomyopathies. Circulation 93(5):841–842CrossRefPubMedGoogle Scholar
  10. 10.
    Cowley CG et al (2003) Safety of endomyocardial biopsy in children. Cardiol Young 13(5):404–407PubMedGoogle Scholar
  11. 11.
    Pophal SG et al (1999) Complications of endomyocardial biopsy in children. J Am Coll Cardiol 34(7):2105–2110CrossRefPubMedGoogle Scholar
  12. 12.
    Zhorne D et al (2013) A 25-year experience of endomyocardial biopsy safety in infants. Catheter Cardiovasc Interv 82(5):797–801CrossRefPubMedGoogle Scholar
  13. 13.
    Vitiello R et al (1998) Complications associated with pediatric cardiac catheterization. J Am Coll Cardiol 32(5):1433–1440CrossRefPubMedGoogle Scholar
  14. 14.
    Soongswang J et al (2005) Cardiac troponin T: a marker in the diagnosis of acute myocarditis in children. Pediatr Cardiol 26(1):45–49CrossRefPubMedGoogle Scholar
  15. 15.
    Soongswang J et al (2002) Cardiac troponin T: its role in the diagnosis of clinically suspected acute myocarditis and chronic dilated cardiomyopathy in children. Pediatr Cardiol 23(5):531–535CrossRefPubMedGoogle Scholar
  16. 16.
    Kleinert S et al (1997) Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression. J Heart Lung Transplant 16(12):1248–1254PubMedGoogle Scholar
  17. 17.
    Aretz HT et al (1987) Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1(1):3–14PubMedGoogle Scholar
  18. 18.
    Cihakova D, Rose NR (2008) Chapter 4 pathogenesis of myocarditis and dilated cardiomyopathy. Adv Immunol 99:95–114CrossRefPubMedGoogle Scholar
  19. 19.
    Durani Y et al (2009) Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 27(8):942–947CrossRefPubMedGoogle Scholar
  20. 20.
    Angelini A et al (2000) Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis. Heart 84(3):245–250CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Emory University School of MedicineAtlantaUSA
  2. 2.Vanderbilt UniversityNashvilleUSA

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