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PED-EM-L  January 2013

PED-EM-L January 2013

Subject:

Re: Myocarditis in children?

From:

Amy Johnson <[log in to unmask]>

Reply-To:

[log in to unmask]

Date:

Thu, 31 Jan 2013 21:29:05 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (170 lines)

I did a literature search on this topic and found these articles (abstracts below). Interestingly, all the articles are from Sweden. From a pathophysiology standpoint, it appears that vigorous exercise during an acute febrile illness with the associated inflammatory response may promote a setup which can increase the risk of myocarditis. I highlighted important parts in yellow. Interesting topic. 





Amy E. Johnson, M.D. 

Childrens Hospital of Colorado 

Department of Emergency Medicine 

University of Colorado School of Medicine 

  

---------------------------------------------------------------------------------------------------------------------------------------------------------- 

Interaction between infection and exercise with special reference to myocarditis and the increased frequency of sudden deaths among young Swedish orienteers 1979-92. 



Friman G , Larsson E , Rolf C . 



Source 



Department of Infectious Diseases and Clinical Microbiology, Uppsala University Hospital, Sweden. 



Abstract 



Infection and fever evoke a cytokine-mediated host response resulting in negative nitrogen balance, muscle protein degradation, which includes the skeletal muscles as well as the heart muscle, and deteriorated muscle function. Physical training has an opposite effect. Moderate physical training also stimulates the immune system, whereas exhaustive and longlasting exercise is followed by a temporary immunodeficiency and an increased susceptibility to respiratory tract infections. Exercise in the acute phase of an infection may promote complications including myocarditis. Exercise in myocarditis is associated with increased organism-associated as well as immune mediated tissue damage. An increased sudden death (SUD) rate among young Swedish male orienteers existed in 1979-92, suggesting (a) common underlying cause(s). Myocarditis was one of the most conspicuous histopathological features. Chlamydia pneumoniae, or a similar organism cross reacting in diagnostic tests, is hypothesized to be a factor causing this increased death rate. High frequency of intense exercise sessions, which was a common practice among the deceased, may have been immunosuppressive, promoting the development of severe myocardial disease. 



PMID: 



9259081 



[PubMed - indexed for MEDLINE] 



Related citations Remove from clipboard 









  



  

Acute infection: metabolic responses, effects on performance, interaction with exercise, and myocarditis. 

Friman G , Ilbäck NG . 

Source 

Department of Infectious Diseases and Clinical Microbiology, Uppsala University Hospital, Sweden. 

Abstract 

Acute infections are associated with multiple host responses that are triggered by cytokines and correlated to fever, malaise and anorexia. The purpose of this systemic acute phase host reaction ("the acute phase response") is to mobilize nutrients for the increased needs of the activated immune system, as well as for energy production and tissue repair. Important effects include wasting of striated muscle, degradation of performance-related metabolic enzymes and, concomitantly, deteriorated central circulatory function. These effects result in decreased muscle and aerobic performance, the full recovery of which may require several weeks to months following week-long febrile infections. Also during early infection and fever, prior to the development of muscle wasting, performance is compromised by other mechanisms. Strenuous exercise may be hazardous during ongoing infection and fever and should always be avoided. In infection, muscle wasting seems to be less pronounced in the conditioned (trained) host than in the unconditioned host. Acute myocarditis most often has a viral etiology but bacteria and their toxins may also be the cause. Furthermore, slow-growing bacteria, previously difficult to diagnose, have emerged as potential "new" causes of subacute to chronic myocarditis. Since myocarditis may or may not be associated with fever, malaise, or catarrhal symptoms, athletes should be taught the symptoms suggestive of myocarditis. Whenever myocarditis is suspected exercise should be avoided. 

PMID: 

9722283 

[PubMed - indexed for MEDLINE] 

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Immunol Cell Biol. 2000 Oct;78(5):510-22. 

Special feature for the Olympics: effects of exercise on the immune system: infections and exercise in high-performance athletes. 

Friman G , Wesslén L . 

Source 

Infectious Diseases, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden. [log in to unmask] 

Abstract 

The elite athlete has a potentially increased sensitivity to respiratory infections, rendering protective measures particularly important. Some other infections that may appear in clusters in the sports setting, such as gastroenteritis, leptospirosis, herpes simplex and viral hepatitis, also require special precautionary attention. Strenuous exercise during ongoing infection and fever may be hazardous and should always be avoided. In addition, early symptoms of infection warrant caution until the nature and severity of the infection become apparent. Because myocarditis may or may not be accompanied by fever, malaise or catarrhal symptoms, athletes should be informed about the symptoms suggestive of this disease. Although sudden unexpected death resulting from myocarditis is rare, exercise should be avoided whenever myocarditis is suspected. Guidelines are suggested for the management and counselling of athletes suffering from infections, including recommendations on when to resume training. Acute febrile infections are associated with decreased performance resulting from muscle wasting, circulatory deregulation and impaired motor coordination, which require variable amounts of time to become normalized once the infection is over. 

PMID: 

11050534 

[PubMed - indexed for MEDLINE] 

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Publication Types, MeSH Terms 



    •   



2. 



  

----- Original Message -----




From: "Bruce Nayowith" <[log in to unmask]> 
To: [log in to unmask] 
Sent: Thursday, January 24, 2013 7:45:48 AM 
Subject: Myocarditis in children? 

Dear List, 
  
A pediatric colleague of mine just told me about an Audio Digest in which a study of young people (teens or children?) who had died in auto accidents were autopsied. Apparently, up to 15% had evidence of past myocardial scarring? 
  
The theory proposed was that many of the viral infections that cause myalgias in children may also cause a bit of myocarditis. And that this occurs on a continuum between myalgias to inflammation to hypertrophic cardiomyopathy…  
  
They recommend no sports for a few days after a febrile illness in children…. 
  
Has anyone else heard this, or did I get my facts mixed up, or ??? 
  
Since I don't do EKGs or troponins on children with myalgias and fever, I don't know how often this happens in my practice. If this is accurate, I am curious about any implications of this in emergency medicine.... 
  
Thanks, 
Bruce Nayowith MD 


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