Case report
Fulminant myocarditis associated with pandemic H1N1 influenza A virus
Miocardite fulminante associada ao vírus influenza A pandémico H1N1
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As setas pretas indicam, da esquerda para a direita, implantação e retirada da assistência ventricular externa. AVE: assistência ventricular externa; FEVE: fração de ejeção; FencVE: fração de encurtamento; VEd: diâmetro do ventrículo esquerdo em diástole; VTI: integral velocidade tempo na câmara de saída do ventrículo esquerdo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Margarida Silva, Nuno Carvalho, Graça Nogueira, Patrícia Costa, Rui Rodrigues, Miguel Abecasis, Manuela Nunes, Rui Anjos, José Neves" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Margarida" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Carvalho" ] 2 => array:2 [ "nombre" => "Graça" "apellidos" => "Nogueira" ] 3 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Costa" ] 4 => array:2 [ "nombre" => "Rui" "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "Miguel" "apellidos" => "Abecasis" ] 6 => array:2 [ "nombre" => "Manuela" "apellidos" => "Nunes" ] 7 => array:2 [ "nombre" => "Rui" "apellidos" => "Anjos" ] 8 => array:2 [ "nombre" => "José" "apellidos" => "Neves" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511200128X?idApp=UINPBA00004E" "url" => "/08702551/0000003100000078/v1_201308021259/S087025511200128X/v1_201308021259/pt/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255112001126" "issn" => "08702551" "doi" => "10.1016/j.repc.2011.11.011" "estado" => "S300" "fechaPublicacion" => "2012-07-01" "aid" => "118" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2012;31:513-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6650 "formatos" => array:3 [ "EPUB" => 201 "HTML" => 5203 "PDF" => 1246 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "513" "paginaFinal" => "516" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Miocardiopatia de takotsubo complicada com trombo apical e alterações da condução" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 978 "Ancho" => 3000 "Tamanyo" => 256630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Results of cardiac catheterization. Left ventriculography at end-systole (A) and end-diastole (B) demonstrating typical apical ballooning and double outline apex suggestive of apical thrombus. Results of selective coronary angiography of the left main coronary artery (C) showing no significant stenosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Sofia Correia, Nuno Moreno, Alexandra Gonçalves, Vítor Araújo, Teresa Pinho, Rui André Rodrigues, Filipe Macedo, Maria Júlia Maciel" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Ana Sofia" "apellidos" => "Correia" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Moreno" ] 2 => array:2 [ "nombre" => "Alexandra" "apellidos" => "Gonçalves" ] 3 => array:2 [ "nombre" => "Vítor" "apellidos" => "Araújo" ] 4 => array:2 [ "nombre" => "Teresa" "apellidos" => "Pinho" ] 5 => array:2 [ "nombre" => "Rui André" "apellidos" => "Rodrigues" ] 6 => array:2 [ "nombre" => "Filipe" "apellidos" => "Macedo" ] 7 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112001126?idApp=UINPBA00004E" "url" => "/08702551/0000003100000078/v1_201308021259/S0870255112001126/v1_201308021259/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Fulminant myocarditis associated with pandemic H1N1 influenza A virus" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "517" "paginaFinal" => "520" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Marta Cabral, Maria J. Brito, Marta Conde, Mário Oliveira, Gonçalo C. Ferreira" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Marta" "apellidos" => "Cabral" "email" => array:1 [ 0 => "mssr.cabral@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Maria J." "apellidos" => "Brito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marta" "apellidos" => "Conde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Mário" "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Gonçalo C." "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Pediatrics, Hospital Dona Estefânia – CHLC – EPE, Lisbon, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Hospital de São José – CHLC – EPE, Lisbon, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Miocardite fulminante associada ao vírus influenza A pandémico H1N1" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2354 "Ancho" => 1584 "Tamanyo" => 331795 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intermediate (A) and high (B) magnification of myocardium with multifocal infiltrates composed mostly of lymphocytes but also some neutrophils, macrophages, plasma cells and eosinophils, associated with myocyte necrosis and ischemia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute myocarditis, albeit rare and potentially lethal, is a well-recognized manifestation of numerous viral infections with a broad spectrum of symptoms and clinical features.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The etiological agents of viral myocarditis include enteroviruses, adenoviruses, parvoviruses, hepatitis C virus, human immunodeficiency virus, influenza, and others.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Coxsackie B virus has been described as the most common pathogen of viral myocarditis and hepatitis C virus is associated with many different forms of heart disease worldwide; however, influenza myocarditis is relatively rare.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Many people are affected by seasonal influenza every year, but the myocarditogenicity of this virus seems to be fairly low. The frequency of myocardial involvement in influenza infection is unclear,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but some studies report that it ranges from 0 to 11%, depending on the diagnostic criteria used to define myocarditis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Myocarditis is an inflammatory disorder characterized by myocyte necrosis and inflammatory infiltrate of the myocardium.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The pathogenesis of influenza myocarditis is also unclear. Host immune response may play a role, as well as direct cytolysis by viral infection.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Fulminant myocarditis is an uncommon complication, typically diagnosed in association with circulatory collapse or at autopsy in patients with influenza-associated fatal outcomes. It may present with fatal arrhythmias, atrioventricular block and/or varying degrees of heart failure, cardiogenic shock being the most severe.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A few case reports and series present incidental diagnoses of influenza-associated acute fulminant myocarditis, but the true prevalence remains unknown.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present a case of rapidly fatal fulminant pandemic influenza A (H1N1) virus (H1N1v)-associated myocarditis, with no previous cardiac symptomatology.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A previously healthy 10-year-old boy presented to the emergency department with a three-day history of a flu-like syndrome: fever, cough, headache, generalized myalgia, vomiting and diarrhea. He had no known risk factors for complications of influenza, he was not previously vaccinated for seasonal or pandemic influenza viruses and he was not receiving any antiviral treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At admission, he was pale and had signs of dehydration. Body temperature was 34.7<span class="elsevierStyleHsp" style=""></span>°C, pulse rate 120<span class="elsevierStyleHsp" style=""></span>beats/min and blood pressure 84/65<span class="elsevierStyleHsp" style=""></span>mmHg (median arterial pressure: 65<span class="elsevierStyleHsp" style=""></span>mmHg). Pulse oximetry showed oxygen saturation of 96–98% and cardiac physical examination was normal. Chest radiography revealed diffuse bilateral alveolar infiltrates. Laboratory findings included 11<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> (84.5% neutrophils), C-reactive protein 2.41<span class="elsevierStyleHsp" style=""></span>mg/dl, and elevated creatinine (1.4<span class="elsevierStyleHsp" style=""></span>mg/dl), glucose (217<span class="elsevierStyleHsp" style=""></span>mg/dl) and phosphorus (8.1<span class="elsevierStyleHsp" style=""></span>mg/dl), with no other abnormalities. The patient's clinical condition improved significantly after intravenous fluid administration; however, when he was hemodynamically stable, sudden asystolic cardiac arrest occurred. Advanced life support was immediately started but was ineffective and the patient died.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Further investigation showed mild elevation of CK, CK-MB and myoglobin. Reverse transcriptase polymerase chain reaction assay from nasopharyngeal swab samples was positive for H1N1v. The autopsy showed multifocal infiltrates composed mostly of lymphocytes but also some neutrophils, macrophages, plasma cells and eosinophils, associated with myocyte necrosis and ischemia, which was compatible with myocarditis (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and excluded the diagnosis of hypertrophic cardiomyopathy. The lung tissue specimen obtained at autopsy showed diffuse pulmonary vascular congestion and extensive alveolar hemorrhage (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Additionally, multisystem histological changes including the cardiac and pulmonary alterations described above, and tracheobronchial and intestinal involvement associated with viral infection were evident, leading to a definite postmortem diagnosis of fulminant viral myocarditis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The prevalence of fulminant myocarditis associated with H1N1v is unknown because of the lack of comprehensive screening, with only a handful of case reports and autopsy findings in the literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Bratincsak et al. reported four fulminant myocarditis cases associated with H1N1v in children and suggested that the 2009 pandemic influenza virus was more commonly associated with myocarditis than seasonal influenza.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The Japanese pandemic influenza registry reported 15 patients with H1N1v-associated myocarditis, ranging from a child to a man over 70 years old.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> According to a report from Canada, only two of 505 children hospitalized with severe influenza infection had myocarditis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There are few individual case reports of fulminant myocarditis from the USA and Europe,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–12</span></a> and a single fatal case was reported in a multicenter pediatric study conducted in Spain.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This is the first report in Portugal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Common cardiac symptoms of myocarditis include dyspnea, chest discomfort, hypotension, peripheral edema and syncope.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the case of myocarditis caused by H1N1v, clinical manifestations vary greatly. Ukimura et al. reported that cardiac dysfunction had progressed rapidly in 12 out of 15 patients, and developed after recovery from flu-like symptoms in two patients. Ten patients with fulminant myocarditis had fatal arrhythmias and/or cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cardiopulmonary arrest as the first cardiac symptom was described in only two patients, as happened with our patient.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Small autopsy-based studies have shown complication rates of myocarditis in fatal cases of 39.4% with Asian flu and 48% with Spanish flu.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> All these fatal cases with myocarditis had severe pneumonia and multiple organ involvement, implying that myocarditis was likely to be a terminally ill state of influenza infection,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as could have been the case with our patient, according to the histopathological findings on autopsy (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>). By contrast, severe viral pneumonia did not precede myocarditis in the 15 cases reported by Ukimura et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Some patients complained only of high fever, without respiratory symptoms before the onset of myocarditis. The findings imply that the H1N1v may have a high affinity for heart tissue in some susceptible patients. In this patient there was initially thought to be an underlying cardiac disease (hypertrophic cardiomyopathy), which could have increased his susceptibility to cardiac complications, but this comorbidity was excluded by histopathology findings. Despite the presence of tachycardia, hypotension and hypothermia secondary to dehydration at admission, the patient was hemodynamically stable immediately before asystolic cardiac arrest and death.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Data on the clinical benefits of antiviral treatment for H1N1v are limited and different authorities have different recommendations. The Hong Kong Hospital Authority Central Committee on Infectious Disease and Emergency Responses (CCIDER) recommend that empirical antiviral treatment be started immediately in patients who are at higher risk for developing complications,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> including those younger than six years, morbidly obese, asthmatic, immunocompromised or pregnant subjects, patients showing no improvement in symptoms 48<span class="elsevierStyleHsp" style=""></span>h after medical treatment and in patients in whom H1N1v infection has been confirmed.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> There are compelling indications for the use of beta blockers and/or angiotensin-converting enzyme inhibitors for the treatment of a subacute phase of the illness; additional supportive intervention is essential as first-line therapy for myocarditis patients with heart failure.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The recent application of intra-aortic balloon pump and/or veno-venous extracorporeal membrane oxygenation (ECMO) in serious cases has yielded good outcomes,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,16,17</span></a> but in this case, despite aggressive management, circulatory resuscitation was not successful. This patient did not receive antiviral treatment, which has been convincingly shown to decrease morbidity and mortality in H1N1v infection. However, as this was a case of fulminant evolution, with rapid progression of inflammatory infiltration, antiviral treatment probably would not have had sufficient time to be effective.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Early detection of myocarditis in patients during influenza pandemics is difficult, as there are no specific symptoms or signs.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To avoid misdiagnosis it is essential to determine the characteristic symptoms, signs and laboratory findings of acute myocarditis,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but it is also important to remember that it can occur suddenly, without any previous suspicious symptom or sign, as was seen in our patient.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This was the first death in the Portuguese pediatric population during the 2009 H1N1v pandemic, and provided arguments for more stringent indications for antiviral therapy in the context of influenza pandemics.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The fulminant form of myocarditis associated with H1N1v may present in the form of fatal arrhythmia, atrioventricular block and/or cardiogenic shock, usually diagnosed in the context of circulatory collapse or autopsy in patients with H1N1v infection, as occurred in this patient.</p><p id="par0075" class="elsevierStylePara elsevierViewall">As the incidence of H1N1v infection continues to rise, physicians should be aware of this rare and potentially fatal complication, since early diagnosis and aggressive supportive measures are essential.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres250452" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238020" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250451" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238019" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-01" "fechaAceptado" => "2011-11-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238020" "palabras" => array:4 [ 0 => "Influenza" 1 => "H1N1" 2 => "Fulminant" 3 => "Myocarditis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238019" "palabras" => array:4 [ 0 => "Influenza" 1 => "H1NI" 2 => "Fulminante" 3 => "Miocardite" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fulminant myocarditis associated with influenza A virus is exceedingly rare, with only a few cases reported in the literature. We describe a previously healthy 10-year-old boy, with a three-day history of flu-like symptoms without antiviral treatment. He was hospitalized with dehydration and hypothermia in the context of persistent vomiting, when he suddenly developed heart failure secondary to fulminant myocarditis. Despite aggressive management, including circulatory support and cardiopulmonary resuscitation measures, the patient died of cardiogenic shock. The postmortem histopathology was compatible with a multisystem viral infection with myocarditis and pulmonary involvement, and H1N1v polymerase chain reaction was positive.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The prevalence of influenza-associated fulminant myocarditis remains unknown. Findings reported in the literature raise the possibility that the novel H1N1 influenza A virus is more commonly associated with a severe form of myocarditis than previously encountered influenza strains.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A miocardite fulminante associada ao vírus Influenza A é extremamente rara, com apenas alguns casos relatados na literatura. Descrevemos um rapaz de 10 anos, previamente saudável, com história de sintomas gripais com 3 dias de evolução, sem terapêutica antiviral. Foi internado por desidratação e hipotermia, no contexto de vómitos persistentes após o que, subitamente, desenvolveu insuficiência cardíaca secundária a miocardite fulminante. Apesar da intervenção imediata, incluindo suporte circulatório e reanimação cardiorrespiratória, o doente faleceu por choque cardiogénico. O exame histopatológico <span class="elsevierStyleItalic">post-mortem</span> foi compatível com o diagnóstico de infecção viral multissistémica, com miocardite e envolvimento pulmonar e a PCR para o H1N1<span class="elsevierStyleHsp" style=""></span>v foi positiva.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A prevalência de miocardite fulminante associada ao vírus Influenza permanece desconhecida. Relatos na literatura levantam a hipótese de o vírus Influenza A H1N1 estar mais frequentemente associado a formas graves de miocardite do que as estirpes sazonais anteriores.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2379 "Ancho" => 1584 "Tamanyo" => 492974 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Low (A) and intermediate (B) magnification of pulmonary parenchyma with vascular congestion and multiple foci of alveolar hemorrhage, without associated inflammation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2354 "Ancho" => 1584 "Tamanyo" => 331795 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intermediate (A) and high (B) magnification of myocardium with multifocal infiltrates composed mostly of lymphocytes but also some neutrophils, macrophages, plasma cells and eosinophils, associated with myocyte necrosis and ischemia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fulminant myocarditis associated with pandemic H1N1 influenza A virus in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 8 | 5 | 13 |
| 2024 Outubro | 40 | 33 | 73 |
| 2024 Setembro | 55 | 22 | 77 |
| 2024 Agosto | 44 | 22 | 66 |
| 2024 Julho | 41 | 29 | 70 |
| 2024 Junho | 35 | 30 | 65 |
| 2024 Maio | 54 | 23 | 77 |
| 2024 Abril | 41 | 30 | 71 |
| 2024 Maro | 40 | 12 | 52 |
| 2024 Fevereiro | 39 | 25 | 64 |
| 2024 Janeiro | 42 | 26 | 68 |
| 2023 Dezembro | 35 | 25 | 60 |
| 2023 Novembro | 30 | 24 | 54 |
| 2023 Outubro | 28 | 15 | 43 |
| 2023 Setembro | 34 | 22 | 56 |
| 2023 Agosto | 29 | 17 | 46 |
| 2023 Julho | 39 | 6 | 45 |
| 2023 Junho | 37 | 15 | 52 |
| 2023 Maio | 40 | 28 | 68 |
| 2023 Abril | 27 | 10 | 37 |
| 2023 Maro | 34 | 24 | 58 |
| 2023 Fevereiro | 28 | 23 | 51 |
| 2023 Janeiro | 38 | 14 | 52 |
| 2022 Dezembro | 43 | 23 | 66 |
| 2022 Novembro | 50 | 25 | 75 |
| 2022 Outubro | 39 | 24 | 63 |
| 2022 Setembro | 33 | 24 | 57 |
| 2022 Agosto | 43 | 30 | 73 |
| 2022 Julho | 35 | 43 | 78 |
| 2022 Junho | 28 | 24 | 52 |
| 2022 Maio | 32 | 31 | 63 |
| 2022 Abril | 47 | 30 | 77 |
| 2022 Maro | 25 | 34 | 59 |
| 2022 Fevereiro | 33 | 22 | 55 |
| 2022 Janeiro | 48 | 17 | 65 |
| 2021 Dezembro | 21 | 27 | 48 |
| 2021 Novembro | 43 | 44 | 87 |
| 2021 Outubro | 60 | 52 | 112 |
| 2021 Setembro | 30 | 31 | 61 |
| 2021 Agosto | 53 | 36 | 89 |
| 2021 Julho | 40 | 25 | 65 |
| 2021 Junho | 35 | 22 | 57 |
| 2021 Maio | 38 | 36 | 74 |
| 2021 Abril | 114 | 54 | 168 |
| 2021 Maro | 94 | 28 | 122 |
| 2021 Fevereiro | 71 | 17 | 88 |
| 2021 Janeiro | 45 | 8 | 53 |
| 2020 Dezembro | 39 | 11 | 50 |
| 2020 Novembro | 64 | 18 | 82 |
| 2020 Outubro | 44 | 12 | 56 |
| 2020 Setembro | 67 | 11 | 78 |
| 2020 Agosto | 52 | 11 | 63 |
| 2020 Julho | 72 | 9 | 81 |
| 2020 Junho | 47 | 6 | 53 |
| 2020 Maio | 95 | 8 | 103 |
| 2020 Abril | 125 | 12 | 137 |
| 2020 Maro | 321 | 18 | 339 |
| 2020 Fevereiro | 266 | 57 | 323 |
| 2020 Janeiro | 135 | 7 | 142 |
| 2019 Dezembro | 85 | 14 | 99 |
| 2019 Novembro | 57 | 7 | 64 |
| 2019 Outubro | 40 | 4 | 44 |
| 2019 Setembro | 68 | 16 | 84 |
| 2019 Agosto | 80 | 7 | 87 |
| 2019 Julho | 65 | 9 | 74 |
| 2019 Junho | 57 | 13 | 70 |
| 2019 Maio | 69 | 9 | 78 |
| 2019 Abril | 41 | 18 | 59 |
| 2019 Maro | 69 | 9 | 78 |
| 2019 Fevereiro | 78 | 7 | 85 |
| 2019 Janeiro | 73 | 3 | 76 |
| 2018 Dezembro | 103 | 12 | 115 |
| 2018 Novembro | 90 | 7 | 97 |
| 2018 Outubro | 167 | 23 | 190 |
| 2018 Setembro | 39 | 11 | 50 |
| 2018 Agosto | 27 | 15 | 42 |
| 2018 Julho | 33 | 9 | 42 |
| 2018 Junho | 38 | 4 | 42 |
| 2018 Maio | 44 | 10 | 54 |
| 2018 Abril | 31 | 7 | 38 |
| 2018 Maro | 60 | 9 | 69 |
| 2018 Fevereiro | 33 | 3 | 36 |
| 2018 Janeiro | 32 | 5 | 37 |
| 2017 Dezembro | 75 | 12 | 87 |
| 2017 Novembro | 55 | 7 | 62 |
| 2017 Outubro | 51 | 16 | 67 |
| 2017 Setembro | 62 | 11 | 73 |
| 2017 Agosto | 85 | 21 | 106 |
| 2017 Julho | 71 | 12 | 83 |
| 2017 Junho | 56 | 16 | 72 |
| 2017 Maio | 67 | 11 | 78 |
| 2017 Abril | 35 | 7 | 42 |
| 2017 Maro | 45 | 4 | 49 |
| 2017 Fevereiro | 49 | 10 | 59 |
| 2017 Janeiro | 47 | 8 | 55 |
| 2016 Dezembro | 49 | 15 | 64 |
| 2016 Novembro | 48 | 12 | 60 |
| 2016 Outubro | 40 | 13 | 53 |
| 2016 Setembro | 33 | 14 | 47 |
| 2016 Agosto | 35 | 20 | 55 |
| 2016 Julho | 15 | 13 | 28 |
| 2016 Junho | 32 | 12 | 44 |
| 2016 Maio | 6 | 14 | 20 |
| 2016 Abril | 88 | 4 | 92 |
| 2016 Maro | 113 | 17 | 130 |
| 2016 Fevereiro | 111 | 21 | 132 |
| 2016 Janeiro | 91 | 11 | 102 |
| 2015 Dezembro | 79 | 17 | 96 |
| 2015 Novembro | 64 | 11 | 75 |
| 2015 Outubro | 79 | 7 | 86 |
| 2015 Setembro | 70 | 10 | 80 |
| 2015 Agosto | 68 | 12 | 80 |
| 2015 Julho | 62 | 7 | 69 |
| 2015 Junho | 38 | 6 | 44 |
| 2015 Maio | 61 | 8 | 69 |
| 2015 Abril | 70 | 12 | 82 |
| 2015 Maro | 69 | 5 | 74 |
| 2015 Fevereiro | 90 | 13 | 103 |
| 2015 Janeiro | 102 | 13 | 115 |
| 2014 Dezembro | 63 | 10 | 73 |
| 2014 Novembro | 62 | 11 | 73 |
| 2014 Outubro | 63 | 16 | 79 |
| 2014 Setembro | 68 | 13 | 81 |
| 2014 Agosto | 64 | 13 | 77 |
| 2014 Julho | 55 | 17 | 72 |
| 2014 Junho | 51 | 8 | 59 |
| 2014 Maio | 92 | 6 | 98 |
| 2014 Abril | 88 | 10 | 98 |
| 2014 Maro | 94 | 18 | 112 |
| 2014 Fevereiro | 120 | 19 | 139 |
| 2014 Janeiro | 164 | 19 | 183 |
| 2013 Dezembro | 85 | 15 | 100 |
| 2013 Novembro | 67 | 16 | 83 |
| 2013 Outubro | 54 | 11 | 65 |
| 2013 Setembro | 61 | 28 | 89 |
| 2013 Agosto | 86 | 16 | 102 |
| 2013 Julho | 90 | 26 | 116 |
| 2013 Junho | 68 | 18 | 86 |
| 2013 Maio | 77 | 28 | 105 |
| 2013 Abril | 95 | 41 | 136 |
| 2013 Maro | 83 | 45 | 128 |
| 2013 Fevereiro | 75 | 33 | 108 |
| 2013 Janeiro | 74 | 40 | 114 |
| 2012 Dezembro | 63 | 21 | 84 |
| 2012 Novembro | 49 | 35 | 84 |
| 2012 Outubro | 43 | 16 | 59 |
| 2012 Setembro | 51 | 13 | 64 |
| 2012 Janeiro | 83 | 0 | 83 |
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