The Multiple Faces of Autoimmune/Immune-Mediated Myocarditis in Children: A Biopsy-Proven Case Series Treated with Immunosuppressive Therapy

Figures

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  Figure 1. Patient 1. (A) Panoramic view showing some endomyocardial samples with severe endocardial thickening and (B) mural thrombosis rich in eosinophilic component (A, Weigert Van Gieson, scale bar 500 micron; B, H&E, scale bar 100 micron). (A) and (C) Two and four chamber CMR T2 weighted images showing subendocardial edema (arrows). (B) and (D) Two and four chamber CMR late gadolinium enhancement (LGE) sequences showing subendocardial fibrosis.

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  Figure 2. Patient 2. (A) Panoramic view showing endomyocardial fragments with fibrous endocardial thickening and (B) replacement‐type fibrosis. (C) At higher magnification, the presence of inflammatory infiltrates is evident, associated with focal myocardial necrosis; note the fibrous endocardial thickening and the replacement fibrosis. (D) The inflammatory infiltrate shows a number of T‐cell lymphocytes >7/mm2 in keeping with active chronic myocarditis (A, Weigert Van Gieson, scale bar 500 micron; B, Azan‐Mallory, scale bar 500 micron; C, H&E, scale bar 200 micron; D, immunostaining anti‐CD3, scale bar 100 micron). (E) and (F) Short axis and four chamber CMR late gadolinium enhancement (LGE) sequences showing almost circumferential subendocardial pattern.

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  Figure 3. Patient 3. (A) Endomyocardial biopsy with oedema and inflammatory infiltrates. (B) The biopsy shows focal replacement‐type fibrosis. (C) At higher magnification, note the inflammatory infiltrates with (D), a number of T‐cell lymphocytes >7/mm2 suggestive for active lymphocytic myocarditis (A, H&E, scale bar 200 micron; B, Azan‐Mallory, scale bar 200 micron; C, H&E, scale bar 100 micron; D, immunostaining anti‐CD3, scale bar 100 micron).