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Seth S. Martin, MD; Caroline L. Hollingsworth, MD, MPH; Stephanie G. Norfolk, MD; Cameron R. Wolfe, MBBS; John W. Hollingsworth, MD
Author and Funding Information

From the Department of Medicine (Drs Martin, Norfolk, Wolfe, and J. W. Hollingsworth), the Department of Radiology (Dr C. L. Hollingsworth), and the Department of Immunology (Dr J. W. Hollingsworth), Duke University Medical Center.

Correspondence to: John W. Hollingsworth, MD, Division of Pulmonary, Allergy, and Critical Care Medicine and Department of Immunology, Duke University Medical Center, 103004 DUMC, Durham, NC 27710; e-mail: holli017@mc.duke.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1546. doi:10.1378/chest.11-0069
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To the Editor:

We thank Dr Das for his interest in our case series published in CHEST (May 2010).1 In his letter, Dr Das emphasizes some of the key clinical data presented in Table 1 of our report on six patients with both pandemic 2009 influenza A(H1N1) (A[H1N1]) and cardiac dysfunction. We agree that other conditions, including but not limited to sepsis, multiple organ dysfunction syndrome, and peripartum cardiomyopathy, may have contributed to the cardiac dysfunction observed in our case series. Limited by the nature of a small case series, we were careful not to assign a causal relationship to the observed association between A(H1N1) and cardiac dysfunction. Regarding Dr Das’s proposal of right-sided heart dysfunction contributing to left-sided heart dysfunction, transthoracic echocardiographic assessment of right-sided heart function was normal in all of our cases except the patient in case 6, who had moderate right ventricular dysfunction. We agree that in hospitalized patients it is difficult to distinguish whether cardiac dysfunction is attributable to direct virally mediated myocarditis, systemic inflammatory response, or other comorbidities. However, we believe it prudent for clinicians to be aware of a high prevalence of cardiomyopathy associated with A(H1N1) in hospitalized patients.

Subsequent to submission of our case series, several reports have emerged suggesting a direct effect of A(H1N1) on the myocardium. For example, Puzelli et al2 described an 11-year-old child with A(H1N1) in Italy who died of myopericarditis and had A(H1N1) isolated from both myocardial tissue and pericardial fluid, providing direct evidence for A(H1N1) effects on myocardial cells. Histologic confirmation of myocardial infiltration with A(H1N1) was obtained in a 5-year-old girl whose death was documented in a series of four cases from a single hospital in California over just a 30-day time period.3 Haessler et al4 reported a case of a previously healthy 24-year-old woman with A(H1N1) and left ventricular dysfunction that improved on serial echocardiograms, consistent with our observations. Beyond traditional echocardiographic assessment, tissue Doppler measurements enabled detection of subclinical cardiac dysfunction in patients from Turkey hospitalized with A(H1N1).5 Furthermore, a report from Japan identified that myocarditis associated with A(H1N1) seemed more common than observed with prior seasonal influenza outbreaks.6

We agree that it is difficult to causally relate cardiac dysfunction to a specific etiology in critically ill patients within a small case series. However, it is our belief that physicians managing patients with A(H1N1) should be aware that transient cardiac dysfunction can occur and may be related to viral myocarditis.

Martin SS, Hollingsworth CL, Norfolk SG, Wolfe CR, Hollingsworth JW. Reversible cardiac dysfunction associated with pandemic 2009 influenza A(H1N1). Chest. 2010;1375:1195-1197. [CrossRef] [PubMed]
 
Puzelli S, Buonaguro FM, Facchini M, et al; Surveillance Group for Pandemic H1N1 2009 Influenza Virus in Italy Surveillance Group for Pandemic H1N1 2009 Influenza Virus in Italy Campania H1N1 Task Force Campania H1N1 Task Force Cardiac tamponade and heart failure due to myopericarditis as a presentation of infection with the pandemic H1N1 2009 influenza A virus. J Clin Microbiol. 2010;486:2298-2300. [CrossRef] [PubMed]
 
Bratincsák A, El-Said HG, Bradley JS, Shayan K, Grossfeld PD, Cannavino CR. Fulminant myocarditis associated with pandemic H1N1 influenza A virus in children. J Am Coll Cardiol. 2010;559:928-929. [CrossRef] [PubMed]
 
Haessler S, Paez A, Rothberg M, Higgins T. 2009 Pandemic H1N1-associated myocarditis in a previously healthy adult. Clin Microbiol Infect. 2011;174:572-574. [CrossRef] [PubMed]
 
Erden I, Erden EC, Ozhan H, et al. Echocardiographic manifestations of pandemic 2009 (H1N1) influenza a virus infection. J Infect. 2010;611:60-65. [CrossRef] [PubMed]
 
Ukimura A, Izumi T, Matsumori A. Clinical Research Committee on Myocarditis Associated with 2009 Influenza A (H1N1) Pandemic in Japan organized by Japanese Circulation Society Clinical Research Committee on Myocarditis Associated with 2009 Influenza A (H1N1) Pandemic in Japan organized by Japanese Circulation Society A national survey on myocarditis associated with the 2009 influenza A (H1N1) pandemic in Japan. Circ J. 2010;7410:2193-2199. [CrossRef] [PubMed]
 

Figures

Tables

References

Martin SS, Hollingsworth CL, Norfolk SG, Wolfe CR, Hollingsworth JW. Reversible cardiac dysfunction associated with pandemic 2009 influenza A(H1N1). Chest. 2010;1375:1195-1197. [CrossRef] [PubMed]
 
Puzelli S, Buonaguro FM, Facchini M, et al; Surveillance Group for Pandemic H1N1 2009 Influenza Virus in Italy Surveillance Group for Pandemic H1N1 2009 Influenza Virus in Italy Campania H1N1 Task Force Campania H1N1 Task Force Cardiac tamponade and heart failure due to myopericarditis as a presentation of infection with the pandemic H1N1 2009 influenza A virus. J Clin Microbiol. 2010;486:2298-2300. [CrossRef] [PubMed]
 
Bratincsák A, El-Said HG, Bradley JS, Shayan K, Grossfeld PD, Cannavino CR. Fulminant myocarditis associated with pandemic H1N1 influenza A virus in children. J Am Coll Cardiol. 2010;559:928-929. [CrossRef] [PubMed]
 
Haessler S, Paez A, Rothberg M, Higgins T. 2009 Pandemic H1N1-associated myocarditis in a previously healthy adult. Clin Microbiol Infect. 2011;174:572-574. [CrossRef] [PubMed]
 
Erden I, Erden EC, Ozhan H, et al. Echocardiographic manifestations of pandemic 2009 (H1N1) influenza a virus infection. J Infect. 2010;611:60-65. [CrossRef] [PubMed]
 
Ukimura A, Izumi T, Matsumori A. Clinical Research Committee on Myocarditis Associated with 2009 Influenza A (H1N1) Pandemic in Japan organized by Japanese Circulation Society Clinical Research Committee on Myocarditis Associated with 2009 Influenza A (H1N1) Pandemic in Japan organized by Japanese Circulation Society A national survey on myocarditis associated with the 2009 influenza A (H1N1) pandemic in Japan. Circ J. 2010;7410:2193-2199. [CrossRef] [PubMed]
 
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