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Influenza B Myocarditis with Cardiac Tamponade
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A3463 - Influenza B Myocarditis with Cardiac Tamponade
Author Block: D. Roto, S. Winters, S. Georas, M. Malnoske; University of Rochester Medical Center, Rochester, NY, United States.
Background - Cardiac complications of influenza infections have been described in the literature since the early 1900s. These complications are more common with Influenza A. Influenza B is often regarded as the less severe counterpart typically causing viral upper respiratory tract symptoms. Myocardial involvement with Influenza B is a rare complication that is better described in children than in adults. However when Influenza B affects the heart, it can lead to profound myocarditis with progressive shock and high risk of death.
Case presentation - A 57-year-old female without past medical history presented to the Emergency Department at the end of May with altered mental status, nausea, and vomiting. She exhibited hypotension with blood pressure of 58/41, tachycardia with heart rate 120, and hypothermia with temperature of 32.4 C. Her physical exam was notable for confusion, weak peripheral pulses and cool, mottled extremities. Initial blood work demonstrated pH of 7, pCO2 32mmHg, pO2 450 mmHg, arterial lactate 9.6 mmol/L and a leukocytosis of 16,300/µL. Despite aggressive fluid resuscitation, she remained persistently hypotensive and required initiation of norepinephrine. Respiratory viral panel on nasopharyngeal swab was positive for Influenza B. Bedside ultrasound demonstrated a large pericardial effusion with tamponade physiology. She underwent urgent pericardiocentesis which led to resolution of pericardial effusion and normalization of the left ventricular ejection fraction. Despite this intervention, the patient continued to exhibit clinically worsening shock and subsequently experienced cardiac arrest, for which resuscitative efforts were not successful. At autopsy, the patient’s lungs did not show evidence of influenza B infection. Histological examination of her heart revealed CD-3 positive lymphocytic infiltration of the myocardium with multifocal cardiac cell necrosis and sub-endocardial septal hemorrhage, consistent with myocarditis due to Influenza B infection. There was no pericardial inflammation present which suggests her pericardial effusion was due to widespread cardiac cell necrosis.
Conclusions - Myocarditis is a rare complication of Influenza B infection in adults and is rarely reported in the literature. Subsequent pericardial effusion with tamponade physiology is a previously unreported event in an otherwise healthy adult without other medical comorbidities. While rare, this is a serious and potentially fatal complication that clinicians should be aware of when evaluating a patient with suspected viral illness who is exhibiting shock physiology.
Author Block: D. Roto, S. Winters, S. Georas, M. Malnoske; University of Rochester Medical Center, Rochester, NY, United States.
Background - Cardiac complications of influenza infections have been described in the literature since the early 1900s. These complications are more common with Influenza A. Influenza B is often regarded as the less severe counterpart typically causing viral upper respiratory tract symptoms. Myocardial involvement with Influenza B is a rare complication that is better described in children than in adults. However when Influenza B affects the heart, it can lead to profound myocarditis with progressive shock and high risk of death.
Case presentation - A 57-year-old female without past medical history presented to the Emergency Department at the end of May with altered mental status, nausea, and vomiting. She exhibited hypotension with blood pressure of 58/41, tachycardia with heart rate 120, and hypothermia with temperature of 32.4 C. Her physical exam was notable for confusion, weak peripheral pulses and cool, mottled extremities. Initial blood work demonstrated pH of 7, pCO2 32mmHg, pO2 450 mmHg, arterial lactate 9.6 mmol/L and a leukocytosis of 16,300/µL. Despite aggressive fluid resuscitation, she remained persistently hypotensive and required initiation of norepinephrine. Respiratory viral panel on nasopharyngeal swab was positive for Influenza B. Bedside ultrasound demonstrated a large pericardial effusion with tamponade physiology. She underwent urgent pericardiocentesis which led to resolution of pericardial effusion and normalization of the left ventricular ejection fraction. Despite this intervention, the patient continued to exhibit clinically worsening shock and subsequently experienced cardiac arrest, for which resuscitative efforts were not successful. At autopsy, the patient’s lungs did not show evidence of influenza B infection. Histological examination of her heart revealed CD-3 positive lymphocytic infiltration of the myocardium with multifocal cardiac cell necrosis and sub-endocardial septal hemorrhage, consistent with myocarditis due to Influenza B infection. There was no pericardial inflammation present which suggests her pericardial effusion was due to widespread cardiac cell necrosis.
Conclusions - Myocarditis is a rare complication of Influenza B infection in adults and is rarely reported in the literature. Subsequent pericardial effusion with tamponade physiology is a previously unreported event in an otherwise healthy adult without other medical comorbidities. While rare, this is a serious and potentially fatal complication that clinicians should be aware of when evaluating a patient with suspected viral illness who is exhibiting shock physiology.
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