| OBJECTIVES:To explore the clinical characteristics and the diagnosis and treatment of acute fulminant myocarditis (AFM) in children.METHODS:To analysis retrospectively the clinical characteristics,the diagnosis and treatment of58children with fulminant myocarditis in Shandong Provincial Hospital Affiliated to Shandong University from January2003to February2014. Clinical manifestation, physical examination, cardiac troponin I(cTnI),cardiac troponin T (cTnT),hypersensitive cardiac troponin T (hypersensitive cTnT) and N-terminal probrain natriuretic peptide (NT-pro BNP) in blood, viral genome detection in blood, electrocardiogram (ECG), transthoracic echocardiography (TTE), cardiac magnetic resonance (CMR), therapeutics and prognosis were summarized and analyzed.10.3%(6/58) of patients were lost.RESULTS:1. Fifty-six patients with AFM had acute heart failure,fourteen suffered from Adam-Stoke syndrome, eighteen had cardiogenic shock,twelve had ventricular arrhythmia,fifteen had Ⅲ°atrial ventricular block(AVB),10case had temporary pacemaker implanted and2case had permanent pacemaker implanted.51(87.9%) patients were cured,5(8.6%) patients died, The time to hospital after onset was2hours to14days (mean,121.0±100.8hours) and the length of hospital stay was2hours to50days (mean,25.7±8.5hours).2. All patients with AFM were suffered from the prodromic infection within two weeks. Twenty-nine patients had respiratory infection, twenty-three patients had digestive system and six patients had fever as the only clinical manifestation.3. Cardiac troponin in100%(56/56) of the patients were elevated and CKMB_Mass in64.7%(33/51) of the patients were elevated.The elevated rate of cardiac troponin were significantly higher than that of CKMB_Mass(P<0.05).The serum concentration of CKMB_Mass in death group were significantly higher than that in cured group(P<0.05).4. NT-pro BNP in100%(38/38) of the patients were elevated. The serum concentration of NT-pro BNP in death patients were significantly higher than that in cured patients(P<0.05).5. Thirty patients with AFM had viral infections including:Epstein-Barr virus (EBV)(20/30), Coxsackie virus(7/30), cytomegalovirus (CMV)(5/30), human herpes virus (HHV)(3/30), parvovirus(2/30),adenoviruses (ADV)(1/30) and influenza virus H1N1(1/30). Of thirty patients,there were nine cases having two kinds of viral infections.6. In the AFM group, ECG findings included mimicking myocardiac infarction (31/58), atrial ventricular block(AVB)(24/58), ventricular arrhythmia(12/58),Low QRS voltage (6/58) and abnormal Q-wave(3/58). The number of abnormal Q-wave in death patients were significantly higher than that in cured patients(P<0.05).7. TTE in94.7%(54/57) of the patients were abnormal.TTE findings included the cardiac enlargement(32/57), reduced systolic wall abnormalities(48/57), regional myocardial thinning(13/57), regional myocardial thickenning (8/57),myocardial echo enhancement(10/57),pericardial effusions(23/57),mitral regurgitation(40/57),tricuspid regurgitation(35/57),mural thrombus(2/57) and the decreased LVEF(18%-58%)(49/58). The measured value of LVEF in death patients were significantly lower than that in cured patients(P<0.05).8. Eleven of fifteen patients with AFM had abnormal CMR. CMR findings included T2weighted signals(1/15), reduced systolic wall abnormalities(4/15), regional myocardial thinning(8/15), regional myocardial thickenning (4/15), Myocardial delayed-enhancement signals(10/15) and pericardial effusions(4/15). 9. Forty-two patients with AFM were treated with high-dose intravenous immunoglobulin.The cure rate of patients using intravenous immunoglobulin (IVIG) was higher than that not using(P<0.05).10. Thirty-six patients were treated with glucocorticoid. The cure rate of patients using glucocrticoid and patients without usage of glucocrticoid had no significant difference(P>0.05).CONCLUSIONS:1. Paediatric fulminant myocarditis presentation occurs acute onset,rapid progress and with the high mortality rate.2. The diagnosis for patients with AFM using cTn is better than that using CKMB Mass.3. The common destructive pathogen of AFM is EB virus,CMV, HSV and AMV.4. The inceased of CKMB_Mass and NT-pro BNP, abnormal Q-wave and the reduced cardiac function were associated with the death rish AFM patients.4. The founding of CMR in AFM group are regional myocardial signal intensity increased in T2-weighted oedeme images and regional myocardial with non-ischaemic regional distribution in inversion recovery-prepared gadolinium-enhanced T1-weighted images.5. The use of IVIG can lower the mortality rate effectively. |
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