A study identifies 2 forms of fulminant myocarditis with covid link

Un estudio identifica 2 formas de miocarditis fulminante con vínculo covid

Patient admitted to hospital.

A study conducted by researchers in France revealed two different forms of fulminant myocarditis related with an infection with SARS-CoV-2 virus. The first is earlylinked to a significant hospital mortalitywhile the other is lateand behave lower gravity and it’s easier to treat as long as it’s diagnosed early. Both phenotypes have different immunological profiles which could help confirm the diagnosis and improve the management of the disease.

The object of the study, carried out on people admitted with fulminant myocarditis induced by Covid-19 from Pitié-Salpêtrière Hospital between March 2020 and June 2021he was compare the clinical characteristics and the evolution of the pathology based on a set of criteria from the American Center for Disease Control and Prevention.

Marc Pineton de Chambrunfrom the intensive medicine department of the Pitié-Salpêtrière hospital and coordinator of the study, declared that “the challenge is to be able to make a diagnose as soon as possible and refer the patient to an appropriate service or a myocarditis management channel. Improving care will depend above all on the medical publications describing these pathologies and on the willingness of physicians to obtain information to recognize them quickly“, in remarks collected in the French edition of Medscape.

After more than two years of pandemic, the clinical pictures of these myocarditis are well described, specified the researcher, specialist in inflammatory diseases. “We must take into account the fact affected patients are usually young. They have Covid-19 usually without lung damage, and they often have chest pain. If in doubt, you should perform a troponin test and a heart ultrasound and you have to seek the advice of a cardiologist or a resuscitator,” he added.

Who can it affect?

The difference between the two forms of myocarditis found in the survey was possible with the increase in the number of cases during the Covid-19 pandemic, specifies Pineton de Chambrun. “We have seen that some patients with covid developed extremely severe myocarditis very early onat the time of viral infection, while others had later myocarditis.

The late form of myocarditis is part of a multisystem inflammatory syndrome similar to kawasaki diseasefirst described in 2020 in children after SARS-CoV-2 infection, and later in adults. Provided it is treated early, this form has a good prognosis. when treated with a combination of corticosteroids and immunoglobulins, the researcher recalled.

The early form of fulminant myocarditis is much more serious and most often affects young adults under the age of 30. It requires urgent recourse to extracorporeal circulatory assistance (ECMO), hence the importance of having immediate access to this type of assistance. The patient recovers spontaneously after two or three days on ECMO“without really understanding why,” said the author.

Unlike the late form, “early fulminant myocarditis has already been observed with other infectious diseases, mainly influenza”. Before the invention of ECMO, “these patients received an emergency heart transplant or they died”. For Pineton de Chambrun, “the challenge is to identify them as quickly as possible plan a treatment with ECMO”, the only way to save them.

What is multisystem inflammatory syndrome?

In order to better characterize fulminant myocarditis associated with infection by the SARS-CoV-2 virus in adults, the team from the Intensive Medicine-Resuscitation Department of the Pitié-Salpêtrière Hospital conducted a study, in partnership with researchers from Inserm and the University of Paris, on cases of patients admitted to intensive care at the Heart Institute of the Pitié-Salpêtrière Hospitalbetween May 2020 and June 2021.

The retrospective study includes data from 38 patients treated for secondary fulminant myocarditis after infection with the SARS-CoV-2 virus. Within this group, a distinction was made between those who presented the diagnostic criteria for multisystem inflammatory syndrome in adults (MIS-A+), whose symptoms are prolonged fever, conjunctivitis, neurological and digestive involvement, and thrombocytopenia, among others) , of those who did not meet these criteria (MIS-A-).

The results of the study show that MIS-A- patients, who represent 33% of cases, had a more recent infection, with an average delay of three days after the onset of covid symptoms. More severe myocarditis more frequently required the use of ECMO, veno-arterial disease, and involved higher hospital mortality. In contrast, in MIS-A+ patients, heart failure appears later, with a median delay of 32 days after infection, and it’s less seriousalthough the virus in this process is undetectable.

This inflammatory syndrome resembles other pathologies already known, such as Still’s disease, a rare systemic inflammatory disease, whose viral origin is suspected. This is the first time that a multisystem inflammatory syndrome has been described by linking it to a viral infection,” explains Pineton de Chambrun.

Which phenotypes could be biomarkers associated with covid?

In addition, the researchers were able to observe that these two the phenotypes are associated with different immunological profiles. In MIS-A- patients, levels of interferon alpha and interleukin-8 (IL-8) are elevated, which is characteristic of an early immune response against viral replication. For their part, MIS-A+ patients have high levels of IL-17, a cytokine known to be involved in several chronic inflammatory diseases, and of IL-22.

Another notable feature in MIS-A- patients is that more than half had anti-RNA polymerase III antibodies. However, these autoantibodies have already been associated by the same research team with recurrent fulminant viral myocarditis linked to influenza. These autoantibodies are also found in sclerodermaa serious systemic autoimmune disease that affects connective tissues.

Pineton de Chambrun notes that “recent data suggest that the RNA polymerase III targeted by these antibodies is involved in antiviral defense. It is possible that these antibodies modify the inflammatory response against the virus. Thus, myocarditis is caused by viral multiplication in the heart after this weak immune response, or by the inflammatory reaction induced by anti-RNA polymerase III antibodies.

“This study shows that fulminant myocarditis associated with COVID-19 represents a heterogeneous entity encompassing two patient phenotypes that differ in clinical, immunobiological and prognostic criteria,” the authors point out. To distinguish between these phenotypes, “they suggest that IL-17, IL-22, interferon, and anti-RNA polymerase III antibodies could be used as biomarkers”.

“For most patients, these biomarkers do not seem essential (in the diagnostic process) because the clinical pictures of these myocarditis, once well understood, are easy to distinguish”, remarks Pineton de Chambrun. On another side, “can be useful in case of doubt. They would also be interested in confirming the viral origin of the myocarditis”.

In conclusion, the research shows that the MIS-A criteria identify two phenotypes within Covid-19-induced fulminant myocarditis. MIS-A+ and MIS-A- patients have a very different clinical presentation, prognosis and immunological profile. According to the authors, the fact of differentiating these two entities seems important for their treatment and to better understand its physiopathology.

Although it may contain statements, data, or notes from healthcare institutions or professionals, the information in Medical Writing is edited and prepared by journalists. We recommend that the reader consult a healthcare practitioner with any health-related questions.

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