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In Reply: Features of Septic Shock and Hepatitis in Parechovirus Myocarditis

Skram, Marius Kurås MD; Nordbø, Svein Arne MD; Døllner, Henrik MD, PhD

The Pediatric Infectious Disease Journal: August 2015 - Volume 34 - Issue 8 - p 913–914
doi: 10.1097/INF.0000000000000762
Letters to the Editor
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Department of Paediatrics, Oslo University Hospital, Oslo, Norway

Department of Medical Microbiology, Norwegian University of Science and Technology, Trondheim, Norway

Department of Paediatrics, Norwegian University of Science and Technology, Trondheim, Norway

The authors have no conflicts of interest to disclose.

Address for correspondence: Marius Kurås Skram, MD; E-mail: mariusskram@gmail.com.

We appreciate the comments from Dr. Eisenhut about myocarditis in patients with human parechovirus (HPeV) infections.1

In our report from December 2014, we described 15 infants with HPeV-3 infection, among whom 3 were diagnosed with hepatitis on the basis of elevated alanine aminotransferase (ALT). These infants also had elevated aspartate aminotransferase (AST), and mean value for ALT was 188 IU/L (normal range 10–60) and AST 610 IU/L (normal range 15–45). Two had a normal echocardiography, and the third patient was not circulatory compromised. Thus, myocarditis was not suspected. Unfortunately, troponin and pro-brain natriuretic peptide levels were not measured.

Myocarditis has been described as a feature of HPeV-1 (former echovirus 22) infection in infants.2–4 We have searched relevant articles and failed to find any description of myocarditis associated with HPeV-3. In a study comparing infantile enterovirus and HPeV infection, myocarditis was detected in 19% (4 of 21) of those with enterovirus and in none with HPeV (0 of 11).5 In cases of infantile deaths associated with HPeV-3, central nervous and pulmonary, and not myocardial, inflammation was highlighted in the autopsy reports.6–8

Myocarditis in not established as a common feature of infantile HPeV-3 infection. Nevertheless, we agree with Dr. Eisenhut that clinicians should be aware of this severe complication in children with HPeV infection and circulatory impairment.

Marius Kurås Skram, MD

Department of Paediatrics

Oslo University Hospital

Oslo, Norway

Svein Arne Nordbø, MD

Department of Medical Microbiology

Norwegian University of Science and

Technology

Trondheim, Norway

Henrik Døllner, MD, PhD

Department of Paediatrics

Norwegian University of Science and

Technology

Trondheim, Norway

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REFERENCES

1. Skram MK, Skanke LH, Krokstad S, et al. Severe parechovirus infection in Norwegian infants. Pediatr Infect Dis J. 2014;33:1222–1225
2. Russell SJ, Bell EJ.. Echoviruses and carditis. Lancet. 1970;1:784–785
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. 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
5. Verboon-Maciolek MA, Krediet TG, Gerards LJ, et al. Severe neonatal parechovirus infection and similarity with enterovirus infection. Pediatr Infect Dis J. 2008;27:241–245
6. Schuffenecker I, Javouhey E, Gillet Y, et al. Human parechovirus infections, Lyon, France, 2008–10: evidence for severe cases. J Clin Virol. 2012;54:337–341
7. Sedmak G, Nix WA, Jentzen J, et al. Infant deaths associated with human parechovirus infection in Wisconsin. Clin Infect Dis. 2010;50:357–361
8. van Zwol AL, Lequin M, Aarts-Tesselaar C, et al. Fatal neonatal parechovirus encephalitis. BMJ Case Rep. 2009;2009
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