Abstract
Although the Epstein–Barr virus (EBV) causes acute infection accompanied by a high fever in young people, there appears to be few reports of a fatal outcome involving myocarditis. We report two cases of unexpected sudden death due to acute myocarditis possibly caused by the EBV. They each visited a hospital due to common cold-like symptoms and unexpectedly died several days later. In both cases, autopsy revealed myocardial necrosis with marked lymphocytic infiltration. Polymerase chain reaction (PCR) screening was positive for the EBV, whereas immunohistochemistry and in situ hybridization for the EBV were negative. Serological investigations showed a mild elevation in antiviral capsid antigen IgG and anti-EBV nuclear antigen IgG in both cases. Immunohistochemical study of lymphocytic infiltrates showed strong positivity for a T-cell marker (CD45R0) in the myocardium and pharyngeal mucosa. These cases suggest the potential risk of mortality from acute EBV infection in young people, even without severe clinical manifestations, and the importance of microbiological investigations, including PCR procedures, in postmortem diagnosis of infectious diseases.
Similar content being viewed by others
References
Bajanowski T, Ortmann C, Teige K, Wedekind H, Zack F, Rose I, Brinkmann B (2003) Pathological changes of the heart in sudden infant death. Int J Leg Med 117:193–203
Siboni A, Simonsen J (1986) Sudden unexpected natural death in young persons. Forensic Sci Int 31:159–166
Aretz HT (1987) Myocarditis: the Dallas criteria. Human Pathol 18:619–624
Nolte KB, Alakija P, Oty G et al (2000) Influenza A virus infection complicated by fatal myocarditis. Am J Forensic Med Pathol 21:375–379
Fornes P, Lecomte D (2003) Pathology of sudden death during recreational sports activity—an autopsy study of 31 cases. Am J Forensic Med Pathol 24:9–16
Lorin De La Grandmaison G, Izembart M, Fornes P, Paraire F (2003) Myocarditis associated with Hashimoto’s disease: a case report. Int J Leg Med 117:361–364
Maze SS, Adolph RJ (1990) Myocarditis: unsolved issues in diagnosis and treatment. Clin Cardiol 15:69–79
Miller R, Ward C, Amsterdam E (1973) Focal mononuclepsis myocarditis simulating myocardial infarction. Chest 63:102–105
Tyson AA, Hackshaw BT, Kutcher MA (1989) Acute Epstein–Barr virus myocarditis simulating myocardial infarction with cardiogenic shock. South Med J 82:1184–1187
Byard RW (2002) Unexpected death due to infectious mononucleosis. J For Sci 47:202–204
Jiwa NM, Oudejans JJ, Dukers DF et al (1995) Immunohistochemical demonstration of different latent membrane protein-1 epitopes of Epstein–Barr virus in lymphoproliferative disease. J Clin Pathol 48:438–442
Shimazaki M, Fijita M, Tsukamoto K et al (2003) An unusual case of primary effusion lymphoma in a HIV-negative patient not pathogenetically associated with HHV8. Eur J Haematol 71:62–67
Aboulafia DM (2002) HHV-8- and EBV-associated nonepidermotrophic large B-cell lymphoma presenting as a foot rash in a man with AIDS. AIDS Patient Care STDs 16:139–145
Komanduri KV, Luce JA, McGrath M, Herndier BG, Ng VL (1996) The natural history and molecular heterogeneity of HIV-associated primary malignant lymphomatous effusions. J Acquir Immune Defic Syndr Human Retrovirol 13:215–226
Kubo M (1998) Clinical studies of human monocyte function. Jpn Med J 113:191–206
Priemer F, Keil W, Kandolf R (1999) Hydrocution in a case of Coxsackie virus infection. Int J Leg Med 112:368–371
Takeuchi H, Kobayashi R, Hasegawa M, Hirai K (1996) Detection of latent infection by Epstein–Barr virus in peripheral blood cells of healthy individuals and non-neoplastic tonsillar tissue from patients by reverse transcription-polymerase chain reaction. J Virol Methods 58:81–89
Schuler T, Kammertoens T, Preiss S, Debs P, Noben-Trauth N, Blankenstein T (2001) Generation of tumor-associated cytotoxic T lymphocytes requires interleukin 4 from CD(+) T cells. J Exp Med 194:1767
Hata H, Sakaguchi N, Yoshitani H et al (2004) Distinct contribution of IL-6, TNF-α, IL-1, and IL-10 to T cell-mediated spontaneous autoimmune arthritis in mice. J Clin Invest 114:582–588
Jager M, Prang N, Mitterer M et al (1996) Pathogenesis of chronic Epstein–Barr virus infection: detection of a virus strain with a high rate of lytic replication. Br J Haematol 95:626–636
Fujiwara M, Shimozono H, Ono H, Fujita N, Nishimura S, Ueda K, Kaneko M (2003) Polyclonal proliferation of lymphocytes containing the Epstein–Barr virus genome in a patient dying of myocarditis in chronic active Epstein–Barr virus infection. J Pediatr Hematol Oncol 25:85–88
Koga M, Fujiwara M, Ariga S, Isumi H, Tashiro N, Matsubara T, Furukawa S (2001) CD8+ T-lymphocytes infiltrate the myocardium in fulminant herpes virus myocarditis. Pediatr Pathol Mol Med 20:189–195
Maisch B, Bulowius U, Schmier K, Klopf D, Koper D, Sibelis T, Kochsiek K (1985) Immunological cellular regulator and effector mechanisms in myocarditis. Herz 10:8–14
Ha SY, Chung CW, Ko YH (2004) Severe chronic active EBV infection in adult patient: case report. J Korean Med Sci 19:453–457
Morey AL, O’Neill HJ, Coyle PV, Fleming KA (1992) Immunohistological detection of human parvovirus B19 formalin-fixed, paraffin-embedded tissue. J Pathol 166:105–108
Tierney RJ, Steven N, Young LS, Rickinson AB (1994) Epstein–Barr virus latency in blood mononuclear cells: analysis of viral gene transcription during primary infection and in the carrier state. J Virol 68:7374–7385
Hebert MM, Yu C, Towbin JA, Rogers BB (1995) Fatal Epstein–Barr virus myocarditis in a child with repetitive myocarditis. Pediatr Pathol 15:805–812
Kitaura Y, Terasaki B, Fujioka S et al (2003) Pathology and pathophysiology of myocarditis. Pathol Clin Med 21:874–885
Okayama S, Fujimoto S, Yutani C et al (2002) A case of recurrent acute myocarditis. Heart 34:731–737
Kawa K (2000) Epstein–Barr virus-associated diseases in humans. Int J Hematol 71:108–117
Shimizu K, Saito O, Ogawa K et al (1999) The sudden death of a junior high school student—school bullying was suspected but the cause of death was viral myocarditis. Res Pract Forens Med 42:259–264
Feldmann AM, McNamara (2000) Myocarditis. N Engl J Med 343:1388–1398
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ishikawa, T., Zhu, BL., Li, DR. et al. Epstein–Barr virus myocarditis as a cause of sudden death: two autopsy cases. Int J Legal Med 119, 231–235 (2005). https://doi.org/10.1007/s00414-005-0540-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00414-005-0540-1