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Letters to the Editor

Features of Septic Shock and Hepatitis in Parechovirus Myocarditis

Eisenhut, Michael MD

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The Pediatric Infectious Disease Journal: August 2015 - Volume 34 - Issue 8 - p 913
doi: 10.1097/INF.0000000000000761
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To the Editors:

A recent report summarized clinical and laboratory features of human parechovirus (HPeV) genotype 3 infection in infants. The authors noted rapid onset of sepsis-like features with mottled skin appearance and in 2 infants hypovolemic shock.1 The fact that creatinine values were normal in the patients studied and the rapid appearance without diarrhea or vomiting reported makes it unlikely that the cardiovascular compromise of the infants was caused by dehydration as stated by the authors. The patient with the highest alanine aminotransferase (ALT)- levels also had shock. The authors did not take into account that the origin of ALT might be the myocardium. Direct evidence for myocarditis caused by HPeV infection is provided by 3 case reports such as a recent one documenting cardiovascular failure and dilated cardiomyopathy associated with HPeV infection.2 Another described a 14-month-old child who died of myocarditis with HPeV cultured from the myocardium and pericardial fluid3 and a 6-week-old boy with clinical and electrocardiographic evidence of myocarditis and HPeV isolated from stool cultures.4

The elevation of ALT might have been myocardial in origin. It is important to recognize myocarditis because of its risk of fatal arrhythmias and the opportunity to provide supportive treatment with inotropes, such as milrinone, dobutamine and diuretics.3 An aid to recognition of myocarditis could be a three-tiered classification: increase in troponin concentration in the absence of another cause and electrocardiographic changes suggestive of acute myocardial injury or abnormal function on echocardiogram or cardiac magnetic resonance imaging.2

Michael Eisenhut, MD

Luton & Dunstable University Hospital

NHS Foundation Trust

Luton, United Kingdom


1. Skram MK, Skanke LH, Krokstad S, et al. Severe parechovirus infection in Norwegian infants. Pediatr Infect Dis J. 2014;33:1222–1225
2. Wildenbeest JG, Wolthers KC, Straver B, et al. Successful IVIG treatment of human parechovirus-associated dilated cardiomyopathy in an infant. Pediatrics. 2013;132:e243–e247
3. Maller HM, Powars DF, Horowitz RE, et al. Fatal myocarditis associated with ECHO virus, type 22, infection in a child with apparent immunological deficiency. J Pediatr. 1967;71:204–210
4. Russell SJ, Bell EJ.. Echoviruses and carditis. Lancet. 1970;1:784–785
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