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A “doença do beijo” e o coração : a propósito de um caso clínico
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O Vírus Epstein-Barr (EBV) é um herpesvírus B linfotrópico que infecta de forma crónica a maioria da população adulta. A infecção aguda sintomática ocorre especialmente em adolescentes e jovens adultos, classicamente manifestando-se por mononucleose infecciosa. Embora seja uma doença frequente, a sua complicação com miocardite é aparentemente rara. A miocardite é definida como uma patologia inflamatória do miocárdio, cuja etiologia é frequentemente viral. No presente trabalho é descrito o caso clínico de um jovem previamente saudável que desenvolveu miocardite aguda, manifestada por dor de tipo anginoso, durante a infecção EBV aguda. O doente evoluiu com resolução das alterações analíticas e electrocardiográficas, mantendo sempre função sistólica ventricular esquerda preservada. Aos 12 meses de seguimento mantinha-se sem intercorrências. Foi realizada uma revisão da literatura relativa à miocardite relacionada com infecção EBV. Apesar da evidência em animais e humanos suportar a existência de cardiotropismo do vírus, com infecção de cardiomiócitos, o papel etiológico na inflamação miocárdica e a capacidade de persistência viral no miocárdio, não foram identificados estudos clínicos sólidos dedicados a esta entidade, embora estudos clínicos com pesquisa de agentes virais em biópsia endomiocárdica de doentes com miocardite e com miocardiopatia dilatada tenham revelado a presença de EBV num pequeno subgrupo. No entanto, os grupos de controlo incluídos não têm dimensão suficiente para estabelecer uma associação inequívoca. Por outro lado, apenas foram encontradas 30 descrições de caso na literatura, que se referem, maioritariamente, a miocardite aguda nos contextos de infecção aguda e de infecção crónica activa em doentes aparentemente imunocompetentes. A epidemiologia, a clínica, a histopatologia e a evolução descritas enquadram-se nas reconhecidas para a miocardite aguda viral. Na infecção crónica activa destaca-se o desenvolvimento de aneurismas coronários. Assim, esta entidade aparenta constituir uma pequena fracção dos casos de miocardite. O nosso caso poderá ser o décimo quarto descrito na literatura em contexto de infecção EBV aguda e o trigésimo primeiro associado a infecção EBV. A continuação do estudo da miocardite associada a infecção por EBV é necessária para esclarecer a história natural face às outras etiologias virais e para sugerir terapêuticas dirigidas aos mecanismos etiopatogénicos.
Esptein-Barr virus (EBV) is a B lymphotropic herpesvirus that chronically infects most of the adult population. Symptomatic acute infection is more common in adolescents and young adults, classically manifesting as infectious mononucleosis. Although this is a common disease, complication with acute myocarditis is apparently rare. Myocarditis is defined as an inflammatory disease of the myocardium and its aetiology is frequently viral. This work describes the case of a previously healthy young adult presenting with acute myocarditis manifesting as pseudo-ischemic chest pain during acute EBV infection. The laboratorial and electrocardiographic changes subsided, and the patient maintained a preserved left systolic function. At 12 months of follow-up the clinical course has been unremarkable. A review of the literature regarding myocarditis in EBV infection was undertaken. Despite animal and human evidence supporting the existence of viral cardiotropism, the ability of the virus to infect cardiomyocytes, its aetiologic role in myocarditis and the capacity for viral persistence in the myocardium, no solid clinical studies dedicated to this entity were found, although clinical studies with viral detection in endomyocardial biopsies had revealed the presence of EBV in a small subgroup of patients with myocarditis and dilated cardiomyopathy. Nevertheless, none of the studies included control groups large enough to establish a clear association. On the other hand, only 30 case reports were found in the literature, mainly describing acute myocarditis in the contexts of acute and chronic active infection in apparently immunocompetent patients. Epidemiology, clinical presentation, histopathology and clinical course were similar to those described in viral acute myocarditis. In chronic active infection, the development of coronary aneurysms stood out. Therefore, this entity seams to contribute to a small fraction of the cases of myocarditis. Our case may be the fourteenth described in the literature in the context of acute EBV infection, and the thirtieth first related to EBV infection. Further investigation on myocarditis related to EBV infection is necessary to clarify its natural history in comparison with the other viral aetiologies and to propose therapeutics targeted at the aetiopathogenic mechanisms.
Esptein-Barr virus (EBV) is a B lymphotropic herpesvirus that chronically infects most of the adult population. Symptomatic acute infection is more common in adolescents and young adults, classically manifesting as infectious mononucleosis. Although this is a common disease, complication with acute myocarditis is apparently rare. Myocarditis is defined as an inflammatory disease of the myocardium and its aetiology is frequently viral. This work describes the case of a previously healthy young adult presenting with acute myocarditis manifesting as pseudo-ischemic chest pain during acute EBV infection. The laboratorial and electrocardiographic changes subsided, and the patient maintained a preserved left systolic function. At 12 months of follow-up the clinical course has been unremarkable. A review of the literature regarding myocarditis in EBV infection was undertaken. Despite animal and human evidence supporting the existence of viral cardiotropism, the ability of the virus to infect cardiomyocytes, its aetiologic role in myocarditis and the capacity for viral persistence in the myocardium, no solid clinical studies dedicated to this entity were found, although clinical studies with viral detection in endomyocardial biopsies had revealed the presence of EBV in a small subgroup of patients with myocarditis and dilated cardiomyopathy. Nevertheless, none of the studies included control groups large enough to establish a clear association. On the other hand, only 30 case reports were found in the literature, mainly describing acute myocarditis in the contexts of acute and chronic active infection in apparently immunocompetent patients. Epidemiology, clinical presentation, histopathology and clinical course were similar to those described in viral acute myocarditis. In chronic active infection, the development of coronary aneurysms stood out. Therefore, this entity seams to contribute to a small fraction of the cases of myocarditis. Our case may be the fourteenth described in the literature in the context of acute EBV infection, and the thirtieth first related to EBV infection. Further investigation on myocarditis related to EBV infection is necessary to clarify its natural history in comparison with the other viral aetiologies and to propose therapeutics targeted at the aetiopathogenic mechanisms.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2017
Palavras-chave
Vírus Epstein-Barr Mononucleose infecciosa Miocardite viral Cardiologia