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      The Possible Role of IVIG in the Treatment of Atrial Fibrillation Accompanied by Fulminant Myocarditis in a 12-Year-Old Pediatric Patient

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          Abstract

          Background

          Fulminant myocarditis (FM) is a potentially lethal condition in children due to rapid progressive hemodynamic instability and cardiogenic shock. Patients with FM might show different clinical manifestations on emergency department admission.

          Case

          Herein, we describe the case of a 12-year-old girl who was admitted to our institution's emergency department due to complaints of abdominal pain and incessant vomiting. However, we detected an early onset of atrial fibrillation (AF) accompanied by FM. The patient's condition of AF and severe hemodynamic disorder was successfully treated in our institution's pediatric intensive care unit.

          Conclusion

          To the best of our knowledge, this is the first report of the co-occurrence of FM and AF successfully treated in childhood. This case report will serve as a guide for the treatment of cases with FM accompanied by AF.

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          Most cited references17

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          Cardiovascular magnetic resonance in myocarditis: A JACC White Paper.

          Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., "Lake Louise Criteria").
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            Negative inotropic effects of cytokines on the heart mediated by nitric oxide.

            The direct effects of pro-inflammatory cytokines on the contractility of mammalian heart were studied. Tumor necrosis factor alpha, interleukin-6, and interleukin-2 inhibited contractility of isolated hamster papillary muscles in a concentration-dependent, reversible manner. The nitric oxide synthase inhibitor NG-monomethyl-L-arginine (L-NMMA) blocked these negative inotropic effects. L-Arginine reversed the inhibition by L-NMMA. Removal of the endocardial endothelium did not alter these responses. These findings demonstrate that the direct negative inotropic effect of cytokines is mediated through a myocardial nitric oxide synthase. The regulation of pro-inflammatory cytokines and myocardial nitric oxide synthase may provide new therapeutic strategies for the treatment of cardiac disease.
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              Fulminant myocarditis: Characteristics, treatment, and outcomes

              Myocarditis is an inflammatory disease of the myocardium with a broad spectrum of clinical presentations, ranging from mild symptoms to severe heart failure. The course of patients with myocarditis is heterogeneous, varying from partial or full clinical recovery in few days to advanced low cardiac output syndrome requiring mechanical circulatory support or heart transplantation. Fulminant myocarditis (FM) is a peculiar clinical condition and is an acute form of myocarditis, whose main characteristic is a rapidly progressive clinical course with the need for hemodynamic support. Despite the common medical belief of the past decades, recent comprehensive data, including a recent registry that compared FM with acute non-FM, highlighted that FM has a poor inhospital outcome, often requires advanced hemodynamic support, and may result in residual left ventricular dysfunction in survivors. This review aimed to provide an updated practical definition of FM, including essentials in the diagnosis and management of the disease. Finally, the outcome of FM was critically revised according to the current published registries focusing on the topic.
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                Author and article information

                Contributors
                Journal
                Case Rep Pediatr
                Case Rep Pediatr
                CRIPE
                Case Reports in Pediatrics
                Hindawi
                2090-6803
                2090-6811
                2021
                20 May 2021
                : 2021
                : 6689865
                Affiliations
                1Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
                2Department of Pediatric Critical Care Medicine, Karadeniz Technical University, Trabzon, Turkey
                3Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
                4Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
                5Department of Pediatric Cardiology, Istanbul Medipol University, Istanbul, Turkey
                Author notes

                Academic Editor: Nina L. Shapiro

                Author information
                https://orcid.org/0000-0001-7693-0261
                https://orcid.org/0000-0002-4290-0491
                https://orcid.org/0000-0003-2413-0320
                https://orcid.org/0000-0003-0849-0705
                https://orcid.org/0000-0001-5164-8534
                Article
                10.1155/2021/6689865
                8163550
                34094611
                30c796b5-9388-4646-a817-387ccf87f7f4
                Copyright © 2021 Can Yilmaz Yozgat et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 23 December 2020
                : 25 March 2021
                : 1 May 2021
                Categories
                Case Report

                Pediatrics
                Pediatrics

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