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research letters

Indian Pediatr 2009;46: 810-811

Intravenous Immune Globulin for Severe Acute Myocarditis in Children


Anwarul Haque, Samreen Bhatti and Fahad J Siddiqui

Department of Pediatrics and Child Health, Aga Khan University Hospital, Stadium Road, P O Box 3500,
Karachi 74800, Pakistan.
Email: anwar.haq@aku.edu
 
 

Abstract

We evaluated high-dose (2g/kg) intravenous immunoglobulin (IVIG) for severe acute myocarditis in 13 children and compared them for survival with 12 children with myocarditis treated with only conventional therapy. Baseline characteristics were similar between the two groups. Both groups had poor left ventricular ejection fraction (LVEF) on admission. The mortality rate was 8% in the IVIG treated children as compared to 46% in controls (P=0.04). Our study supports the use of IVIG in severe acute myocarditis in children.

Key Words: Child, Immunoglobulin, Left ventricular ejection fraction, Myocarditis.


We conducted this study to assess the effectiveness of intravenous immune globulin (IVIG) in children with acute severe myocarditis. For this, we studied case-records of all infants admitted with clinical diagnosis of acute myocarditis in our PICU between 2004 to 2007. The diagnosis of acute myocarditis was established clinically on the basis of the history combined with supporting physical examination, relevant investigation and evidence of decreased left ventricular function on echocardiography(1). Children with pre-existing structural heart defect, cardiomyopathy, coronary anomaly, sepsis, or Kawasaki’s disease were exclu-ded. Endomyocardial biopsy was not done. Patients were divided into two groups: Group I – who received aggressive supportive care and high-dose IVIG (n=13) (2 g/kg over 16-24 h on day of admi-ssion) and Group II – who received only supportive care and no IVIG(n=12). The study was approved by the institutional ethical review committee.

Baseline characteristics of the two groups are compared in Table I. All of them have antecedent illness (either gastrointestinal or respiratory; mean 2 days), tachypnea and tachycardia for age, hepato-megaly, gallop murmur, pulmonary edema and severe metabolic acidosis. Cardiac troponin (cTnI) was done in Group I only and was markedly elevated (mean 2ng/mL) (normal value <1). All of them received mechanical ventilation for cardiores-piratory support. No adverse effect was observed from immunoglobulin administration. In Group I, only one patient (8%) expired as compared to 6/13 (46%) in Group II (P=0.04). Recovery of left ventricular function was not significantly different between two groups (49% vs. 46%) (P=0.13).

TABLE I



Patient Characteristics of Two Groups
Variables IVIG-
(controls)
n = 13
IVIG+
(cases)
n =12
P
value
Age (mo), mean(SD) 12.0 (4.9) 7.3 (5.8) 0.04
Gender (M/F) 6/7 6/6 0.6
Hepatomegaly 12 9 0.3
Cardiomegaly 12 12 0.5
ECG: Low-voltage 12 9 0.3
Initial EF (%), mean(sd) 22.5 (11.1) 17.5 (5.0) 0.17
Inotropes 1.5 (0.9) 3.0 (1.1) 0.001
EF: ejection fraction

Our reports showed that IVIG group had significant higher survival rate (92%) than other group who did not receive IVIG (54%). The therapeutic efficacy of high-dose IVIG in Kawasaki disease has been already established(2). Other experimental animal and human studies in acute myocarditis have also reported better outcome with IVIG(3-6).

Our study had few limitations. The diagnosis was based on clinical features, CXR, ECG, and echocardiography. Small sample size and retrospective nature of the study were the other hinderances. However, this study provides support for aggressive supportive care and early use of IVIG in acute myocarditis in children.

References

1. Levi D, Alejos J. Diagnosis and treatment of pediatric viral myocarditis. Curr Opin Cardiol 2001; 4: 171-181.

2. Newburger JW, Takahashi M, Burns JC, Beiser AS, Chung KJ, Duffy CE, et al. The treatment of Kawasaki syndrome with intravenous gamma globulin. N Engl J Med 1986; 315: 341-347.

3. Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL, Takahashi M, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. 6. Circulation 1994; 89: 252-257.

4. Goland S, Czer LS, Seigel RJ, Tabak S. JordanS, Luthringer D, et al. Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy: series of six patients and review of literature. Can J Cardiol 2008; 24: 571-574.

5. McNamara DM, Rosenblum WD, Janosko KM, Trost MK, Villaneuva FS, Demetris AJ, et al. Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation 1997; 95: 2476-2478.

6. Kishimoto C, Shioji K, Kinoshita M, Iwase T, Tamaki S, Fujii M, et al. Treatment of acute inflammatory cardiomyopathy with intravenous immunoglobulin ameliorates left ventricular function associated with suppression of inflammatory cytokines and decreased oxidative stress. Int J Cardiol 2003; 91:173-178.
 

 

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