Question for Dr. Fett

[burtongirls]

Dr. Fett,

I had a severe reaction (Steven Johnson Syndrome) to a sulfa-based antibiotic just prior to my ppcm diagnosis. A week later, I was diagnosed with ppcm with an EF of 30-40%. I've researched the antibiotic I was taking, and it has been reported to cause allergic myocarditis. Is there any possiblity that my low EF was caused by the meds and not by the pregnancy? I know there's no way of knowing for sure, but, in theory, if the low EF was medicine-induced, then would a second pregnancy pose a threat?

Thank you!!!

[JAMESFETT]

Yes, it is possible that an allergic myocarditis could have led to your decreased EF (heart failure), since that is known to happen, for example following smallpox vaccinations, a very few people develop a type of allergic myocarditis and heart failure, usually treatable and reversible. The only way to know would be by endomyocardial biopsy and finding typical findings of eosinophile cells infiltrating the heart muscle. This is another reason for doing biopsy in PPCM patients who are not improving in the first 2-3 months or so after diagnosis, because one wants to be sure about the process that is going on, including the presence or absence of viral genômes (viral DNA or RNA material). There is another conditioin, called "giant cell myocarditis" that may be similar, but has a much more rapid course, and biopsy is helpful to identify that. It is important to identify in the differential diagnosis because without the very correct treatment mortality rate is very high. Treatment with ACE-I and B-B would be helpful to improve the heart failure, but we also have evidence that those two categories of medication profoundly affect the immune system and dampen an overactive immune process as may be seen in an autoimmune myocarditis.

JDF

[JAMESFETT]

P.S. I think the risk of relapse in a subsequent pregnancy would be similar even if it had been an allergic myocarditis (which is basically a type of autoimmune myocarditis--as is PPCM and some forms of IDCM) and the most important determining factor about outcome and successful completion of pregnancy would be recovery of left ventricular function prior to a subsequent pregancy--in which the risk of recurrence is very low.

JDF

[burtongirls]

Dr. Fett,

Thanks for your response. I read about the allergic myocarditis and the need for biopsy a few months ago and took it to my cardiologist. He totally dismissed me, and said that a biopsy at this point won't tell us anything. Is he right? I was diagnosed 7 months ago. My EF has returned to normal.

Thanks!

[JAMESFETT]

Your cardiologist, I think, is right. There could be no justification at this time to do a biopsy because a)you have recovered function, b)there is a small risk of complications, and c)no different treatment would be necessary or recommendable. Should you consider a future pregnancy, I think the tests that might be helpful would be a)normal blood high sensitivity C-reactive protein, b)continuing normal echo heart function, and c)normal baseline blood B-type natriuretic peptide.

JDF

JDF

[burtongirls]

Thanks, Dr. Fett,

Can you please explain what tests A and C are in your last response? I know what an echo is...I'm very familiar with those! Thanks!

[JAMESFETT]

Briefly,
1)BNP is a measure of a type of hormone secreted by the failing left ventricle. It is most helpful in sorting pulmonary causes of shortness of breath from heart failure causes of shortness of breath. It also has a usefulness in long-term monitoring of status of left ventricle, when compared with baseline levels, and
2)hs-CRP is a measure of an inflammatory process, one of which may be inflammation in the heart (myocarditis). I have found it to be elevated in almost every new PPCM patient at diagnosis, and we have, based on early testing, placed the cut-off level at 10 mg/Liter. Pregnancy, itself, may cause some elevation, that is why we set the cut-off higher.

There are quite a few other threads in these forums dealing with this, and we cover it in our 2005 International Journal of Gynecology and Obstetrics article [2005;90:161-6, see Entrez Pub Med, search "peripartum cardiomyopathy" or "fett jd"].

JDF

[burtongirls]

Thanks again! Sorry if I caused you to repeat yourself, sometimes I get so overwhelmed with all of the wonderful information on this forum that I don't know where to look for a specific answer. This info is especially helpful as I plan on mentioning it to my doctor. Like I said before, he's incredibley dismissive of any and all research I bring him, but I'll keep trying!

[burtongirls]

Hi Dr. Fett,
Thanks so much for your dedication to this site...it really does mean so much to us. In a previous post, you said that the chance for a relapse in a sub. pregnancy would still exist even if my CM was caused by my allergic reaction to bactrim. Can you explain this to me? Thanks!

[JAMESFETT]

Whatever initiates the process--perhaps viral infection--the next step is involvement of the immune system in many different ways, so that the process transitions to an autoimmune myocarditis. An allergic myocarditis, once experienced, leaves the mechanisms there that carried it along in the first place, even if the initiating substance is no longer present that started it. A subsequent pregnancy blunts the immune system and at the end of the pregnancy the immune system begins to return to normal, so that any upset balance may become exaggerated. I think however, that if it had been an allergic myocarditis rather than a typical PPCM myocarditis that the risk of relapse is less than for the PPCM patient (estimate, around 5 % compared to 10 %).

JDF