Wednesday, February 9, 2022

TROUBLESHOOTING MYOCARDITIS


 By Bobbi Kline, MD (Integrative Physician / Genomic Research Specialist)

As a mom, my heart grieves for parents, including Elysa’s, who suffer such devastating tragedy. It’s the worst thing you hope never happens to your child, and I truly admire parents who turn a tragedy into something positive. It requires such amazing strength, courage and grace. As a physician, I find my self immediately asking "Why do these things happen? How can we predict or prevent them?" As clinicians, we look for patterns to help guide diagnosis and treatment. We know what to expect, but sometimes they can lull us into a false sense of security. Childhood viruses, as any parent knows, are an expected part of those early years. 

But what happens when they turn out to be something more? That’s where pattern recognition is crucial. When something obviously falls outside those patterns, it’s a signal to question and go deeper. But what happens when you don’t even recognize that deviation? What if something is so uncommon or so subtle that it’s hard to detect among all the noise? Post-viral myocarditis is one of those conditions, and I’m glad to see it now in the spotlight. Raising awareness is a key first step. While COVID-19 has certainly helped to highlight this condition, it goes further than COVID. Many common childhood viruses have been implicated in causing myocarditis, but most people are completely unaware. I admit that it was not something I ever really thought about as my kids were growing up. And I am not alone. Educating clinicians as well as parents on what to look for, when to be alarmed, when to go deeper is crucial. This alone will save lives. 

But it’s only the first step.
We also need better tests and tools to quickly and easily identify who is at risk, and better treatments for helping these children. This requires a multidisciplinary approach that includes better diagnostics including noninvasive technology, along with effective medications and other treatments. It also includes the burgeoning field of genomics and personalized medicine, both to provide a better understanding of the why, as well as a powerful tool to predict and prevent. For, at the heart of this, is understanding each child’s uniqueness in a way that empowers.  Two studies have been published this year that have the potential to leverage the power of DNA to identify who is at risk for developing myocarditis after a viral infection. Not only that, but also which of those children are most likely to recover, and therefore need fewer interventions, and which of those children are most at risk for sudden death and require much more intensive treatment and support. And, in today’s world, we also need the power of legislation to make sure everyone has access to this higher level of care. There is much promise to change the trajectory of this devastating illness, and it is only through advocacy such as this that it will happen. 


PEDIATRIC MYOCARDITIS & NATIONAL DETECTION MOVEMENT (Part 1)

Written by: Dr. Robert L. Bard

Since the advent of Covid-19 Long Haul studies in 2021, the medical diagnostic community shifted into overdrive- seeking out all available screening and examination protocols to assess health problems called POST-ACUTE SEQUELAE (PASC). One of the recent Covid-19 related headliners is the rise in cases of MYOCARDITIS in children 16 years and under. CDC Reports link the pathological impact with covid infection since it is proven that Viral infections are a common cause of myocarditis. 

Between early 2020–2021, patients with Covid-19 had nearly 16 times the risk for myocarditis[1]. According to the CDC, in a study of myocarditis cases, 2,116 (41.7%) had a history of Covid-19.  In addition, cases of myocarditis reported to the Vaccine Adverse Event Reporting System (VAERS) indicated links between Myocarditis and Pericarditis to come from the mRNA Covid-19 vaccination (especially in male adolescents and young adults) more often after the second dose.[2].


Myocarditis is defined as an inflammatory disorder of the heart muscle (myocardium) leading to cardiac dysfunction. It is also recognized as myocardial cell death 
[3]. Checkups for this also reviews for PERICARDITIS (the inflammation of the outer lining of the heart). Various causes of myocarditis includes: Viral Infectious including adenoviruses, echoviruses, enteroviruses like the coxsackie viruses. In addition, predisposition can occur from those with Autoimmune diseases such as Celiac disease, Churg-Strauss syndrome, Crohn disease, Kawasaki disease, lupus, rheumatoid arthritis, sarcoidosis etc. (See NIH chart for full list of causes- [4])

STANDARDIZED DIAGNOSTICS
As with any critical disorder, detecting early stages of myocarditis allows for a higher opportunity to treat and even eliminate the health risk.  In children, symptoms include: Fever, Fainting, Breathing difficulties, Rapid breathing, Chest pain and Rapid or irregular heart rhythms [5]. In adults, symptoms range from chest pain, shortness of breath, at rest or during activity and fluid buildup with swelling of the legs, ankles and feet. To prevent possible heart damage, a cardiologist may order one of a number of imaging options:

▪ Electrocardiogram (ECG or EKG)
▪ Chest X-Ray
▪ Heart MRI
▪ Blood Tests
▪ Doppler Ultrasound for Acute Myocarditis
▪ Cardiovascular MR Elastography (MRE)
▪ Ultrasound Elastography

See expanded details on diagnostic protocols, visit:  http://pediatricscan.com/myocarditis.html



NEW GROUP: MEET MOMMIES ON A MISSION! 
THE 2022 NATIONAL "ONE VOICE" FOR CHILDREN COLLECTIVE
In Feb. 2022, lead directors of The AngioFoundation, The NY Cancer Resource Alliance and publishers of PREVENTION101.org forged a collaborative outreach community project with the For Elysa Foundation (myocarditis awareness org) to form a national coalition of clinical support associations, research foundations, researchers and parent groups dedicated to the awareness of rare pediatric diseases and critical disorders. This collective concept called "MOMMIES ON A MISSION" is a unique and remarkable platform that aspires to support the many pediatric disorders that plague today's children.

Known as 'Project One", Mommies on a Mission will launch the ONE VOICE crusade to leverage new awareness response for the deadly health threat of Myocarditis in America's children. "MOMMIES ON A MISSION" is a creative title Mrs. Jana Rojas (director of For Elysa Foundation) used to describe her fellow advocates who, like her, established a dedicated benevolent program to battle pediatric myocarditis through education, awareness and to support clinical research. Even more are driven to forge standardized screening of myocarditis as part of a national prevention and early detection initiative. "Losing another child to this terrible and insidious disease is one child too many! It's time we joined hands with all groups, legislators, medical societies and anyone who can make a difference. We hope to deploy a multi-stage battle plan to address this disease and enact new solutions in every pediatrician's office!", states Dr. Noelle Cutter (Molloy College, NY Cancer Resource Alliance).



MedNews Extra
Saving Lives Through Advocacy & Research:
FOR ELYSA FOUNDATION

Around the first week of Feb, 2022, our clinical diagnostic researcher, Dr. Robert Bard launched his PediatricScan.com 2.0 in NYC‐ which included a Pilot program for Myocarditis Screening through the use of advanced Doppler Ultrasound Imaging.  To establish the clinical network for this program is to connect with ICU specialists & Cardiologists as well as all associations supporting Myocarditis research.

We met the directors of a remarkable national advocacy foundation called FOR ELYSA FOUNDATION‐ a non‐profit organization dedicated to promoting Education, providing Light, and supporting Research in the areas of viral myocarditis and pediatric sudden cardiac arrest. (www.ForElysa.org). Mrs. Jana Rojas and husband Jaime Rojas from Kansas City developed this organization inspired by the loss of her vibrant little girl,  Elysa Louise Rojas who passed away at the tender age of two years old. " In Elysa’s case, a common childhood virus was responsible for her myocarditis. The virus either attacked Elysa’s heart directly or caused her immune system to attack her heart muscle in a “friendly fire” fashion while trying to fight the virus. The inflammation in her heart increased drastically and very quickly to the point of sudden cardiac arrest. Doctors and scientists do not fully understand the mechanisms within the body that cause a virus to “go haywire” in the immune systems of individuals with myocarditis. There is currently no way to predict when/if this will occur."



The FOR ELYSA FOUNDATION is one of our first advocacy friends in pursuit of bringing national awareness and supportive clinical research for myocarditis diagnostics and prevention. According to the ForeElysa.org website, Myocarditis is a disease marked by inflammation and damage of the heart muscle. There are many causes of myocarditis, including viral infections, autoimmune diseases, environmental toxins, and adverse reactions to medications. The most common cause of myocarditis in North America is viral infections. Myocarditis usually attacks otherwise healthy people. It is believed that 5 to 20% of all cases of sudden death in young adults are due to myocarditis. Although the exact incidence of myocarditis is not known, it is estimated that approximately 343,000 people die of myocarditis and its major complication, cardiomyopathy, each year. The prognosis is variable but chronic heart failure is the major long term complication. Myocarditis and the associated disorder of idiopathic dilated cardiomyopathy are the cause of approximately 45% of heart transplants in the United States.  

Materials in this excerpt are published with express consent from The For Elysa Foundation.  For complete Information, visit www.FORELYSA.org



HOW & WHEN TO CHECK FOR PEDIATRIC MYOCARDITIS
By: Jana Rojas
The tricky thing with myocarditis being virally mediated is that Elysa could have had a heart scan a week before she died (the day before she contracted the virus that wrecked her heart), and it would have been normal. I am hesitant to insinuate that imaging could "clear" a patient and provide a clean bill of health without noting that this can and does occur spontaneously after viral infections, and so testing while ill or post-virally is actually the key message and window of opportunity for myocarditis detection.
In my mind, the primary role for cardiac diagnostic imaging as it related to myocarditis specifically would be for: 
1) acutely ill children in ED/urgent care/hospital inpatient settings
2) children exhibiting the signs and symptoms you have outlined (fainting, sudden fatigue, shortness of breath, chest pain, palpitations), 
3) after known Covid or other viral infection with prolonged or delayed healing (ie ongoing fatigue, shortness of breath, etc)  
4) and possibly PRE-PARTICIPATION SPORTS PHYSICALS. The pre participation screenings would be enhanced cardiac screenings in general to ideally pick up congenital heart defects and other concerns as well as myocarditis. 








1) Morbidity and Mortality Weekly Report (MMWR): Association Between Covid-19 and Myocarditis Using Hospital-based Admin Data 3/2020-1/2021) https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e5.htm
3) MR Imaging of Myocardial Infarction | RSNA-Radiological Society of North America  / https://pubs.rsna.org/doi/10.1148/rg.335125722
4) The Diagnostic and Clinical Approach to Pediatric Myocarditis: A Review of the Current Literature (NCBI/NIH)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352488/
5) Diagnosis and Management of Myocarditis in Children (American Coll. of Cardiology) https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

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