Parvovirus B19-induced angiogenesis in fulminant myocarditis

A 33-year-old male patient was admitted to our hospital with fever, diarrhoea, and symptoms of cardiogenic shock after cross-country running. Laboratory data showed an lactate of 4.5 mmol/L, increased troponin t (18 557 ng/L), and creatine phosphokinase levels of 4404 U/I. Coronary angiography demonstrated normal coronary arteries with no electrolytic disturbances. Cardiac index of 1.2 L/min/m2, mean arterial pressure of 45 mmHg, a pulmonary artery pulsatility index of 0.7, and a pulmonary capillary wedge pressure of 0.8 were additionally indicating a beginning right heart failure. Transthoracic echocardiography revealed right and left ventricular dysfunction with an ejection fraction of <5% and marked oedema of the left ventricular wall (Panel A, Supplementary material online, Movies). A veno-arterial extracorporeal membrane oxygenation was used as bridging for the biventricular failure, before an orthotopical heart transplant was promptly performed. A viral infection by parvovirus B19 was serologically confirmed. The explanted heart tissue (Panel B) was analysed by scanning electron microscopy (SEM) (Panel C) and serial section SEM (Panel D). Electron microscopy showed a pronounced muscular oedema (Panels B and C, Supplementary material online, Images) with a severely disturbed, partly feathered course of heart muscle fibres (Panel D), and extensive inflammatory infiltrates of lymphocytes (Panel E, red arrowheads).