Viruses and DCM

[heartfulloflove]

I know there is a connection between cytomegalovirus and DCM. I was wondering what other viruses have been indentified to cause DCM?

[JAMESFETT]

The very best article and information on this relationship of virus and myocardiopathy of DCM/IDCM comes from Kuhl and colleagues, reported in 2005 Circulation. 112:1965-70. "Viral persistence in the myocardium is associated with progressive cardiac dysfunction." The viruses identified in their report included coxsackievirus, parvovirus B19, adenovirus, and herpesvirus.

JDF

[heartfulloflove]

Excellent info Dr. Fett, thank you. I know many cardiologists suspect viral causes in DCM cases for which there is no other explanation. A couple of those viruses seem common. I'm assuming developing a heart problem is a rare result. It makes me wonder what makes one person susceptible while another is not.

[Mindyt]

My cardiologist mentioned the coxsackie virus to me when I was diagnosed. No way to tell if that is what it was but it was one of the viruses he mentioned.

[JAMESFETT]

Those viruses are common. That is why simple presence of antibodies in the blood, indicating past exposure, proves nothing. It is necessary to find by polymerase chain reaction (PCR) testing, viral genômes in heart tissue or in the blood, indicating active replication. I believe that those who could potentially develop a heart complication (myocarditis) are those who have a genetic susceptibility in addition to the pregnancy-blunted immune system that permits the virus to remain and become active, whereas if not pregnant, and no change in the immune system, the virus would be "like water off a duck's back." It's also a matter of timing, if exposure to that virus first occurs during or just befoe or just after pregnancy, it can cause problems when at other times it would do nothing at all. In addition there may be a particularly virulent strain of that virus in a community, which could account for some "clustering" of PPCM, and in the case of Haiti, I believe the virulent virus pool is larger than in some places.

JDF

[christa]

In those of us who were diagnosed with the second pregnancy, but suspect we had ppcm during the first, was the virus dormant? or what?

[JAMESFETT]

In that situation, the viral issue is uncertain; and would require biopsy with PCR testing of "quickfreeze" biopsy specimen. More and more reports are coming out about viral genômes (RNA or DNA viral particles) in IDCM biopsied hearts, and so far, only one report in the literature (plus one by personal communication, not yet published) finding viral genômes in PPCM biopsied hearts. If you had PPCM with the first pregnancy, but didn't recognize it, and then developed heart failure and diagnosis of PPCM in the next pregnancy, there may or may not have been viral genômes present. Those for whom it is worth doing biopsies would be those who are not improving in the first few weeks and months following diagnosis. If there is recovery, then no need to do biopsy because no treatment would be indicated, and that would just be a small risk of complications without any benefits. However, should viral genômes be found, there is now at least one anti-viral treatment available (Interferon B) and more being investigated. There have been a lot of developments just in the past 6 years.

JDF

[heartfulloflove]

I have a theory that different pregnancies change the immune system in different ways, because each one is so different.

In regard to the possibility of my prior cytomegalovirus playing a role, there is a concern I had. I've read nothing about such a severe infection like the one I had happening to someone with a normal immune system. Recall I had liver and spleen enlargement and crippling fatigue. It was a long and difficult six month recovery, and I used to be a ball of constant energy. I never ever fully recovered my pre-CMV energy levels, I'm probably at 75%. Do "normal" people get severe acute CMV like that?

[JAMESFETT]

Cytomegalovirus can do just that. PCR testing of heart tissue has also identified CMV genômes present in cardiomyocytes of DCM patients, and that has been published in various reports. Pregnancy can alter the immune system such that CMV, whether dormant or new (like other cardiotropic viruses) can be the reason for the re-activation and/or the severity of infection. I would not be at all surprised, if only there were a way to confirm it, that CMV is the culprit in your case. It's all a matter of timing, just like a collision of two cars, that happen to come together at the same intersection at the same time. They may each have passed that intersection numerous times without mishap because they never, until impact, met at the same intersection at the same time. Is that fate, destiny, or pure happenstance? I have in mind that at some stage in filling knowledge gaps we will be able to immunize women of reproductive age (or every child) against cardiotropic viruses, and we will then wipe out viral myocarditis with complicating dilated cardiomyopathy and heart failure.

JDF

JDF

[heartfulloflove]

Is a person who has had one cardiotropic virus more prone to problems from other cardiotropic viruses?

[JAMESFETT]

That is unknown, but possible, because in PCR testing of heart muscle cells (cardiomyocytes) there have been reports of more than 1 virus identified (2 or 3) in a single sample, and it is even possible that in some instances the combination is necessary for damage or that worse damage results with the combination. Testing used to be done for just one cardiotropic virus (enterovirus or coxsackievirus B5) and a negative report resulted in "no virus found" comment. That was not adequate because it became clear that if one did PCR testing, it is necessary to do a battery of testing, including for coxsackievirus, adenovirus, parvovirus B19, cytomegalovirus, herpesvirus, and maybe Hepatitis B virus. The reason this is so important is because if one does limiited testing and concludes "no virus" but there is indeed another virus for which tests were not done, and in that situation, immunomodulatory therapy were to be given, but not antiviral treatment, the patient could actually worsen.

JDF

[heartfulloflove]

Wow, so there are reports out there that say 'no virus' simply because the study only tested for a couple of the several known? I wonder how far that set back DCM research. Kind of sad.

[JAMESFETT]

Knowledge comes about slowly with stops and starts. Sometimes we think we know something, but someone else digs a little deeper, and then we realize there was still much more to learn. One of the best examples in PPCM is the French investigator in about 1986 who declared categorically that the humoral immune system was not at all involved in PPCM, because they could find no autoantibodies in the blood, and antibodies come from the humoral immune system and B-lymphocytes. For a time I was tempted to believe him until we began to find multiple autoantibodies, new ones never before recognized, plus the old ones on our Haitian PPCM patients, and our knowledge about the immune system in PPCM has grown incrementally since 2000. Now we know those 1986 tests were not sensitive enough. That's why it takes multiple researchers and repetition of previous findings as well as continuing search for new findings to make real progress.

JDF

[heartfulloflove]

And curious minds! I love science.

[sfekke]

Whenever we talk about CMV, cytomegalovirus -sp? I get nervous thinking about my son possibly being exposed to this while in my womb. I feel a little like a hypochondriac asking my pediatrician to check his heart and other organs possibly effected by cardiotropic viruses. I posed the question on the last visit and he wanted my cardiologist to make the call.

Does anyone know what concerns are there regarding the infant if these viruses are found to be contributing to PPCM?

Thanks,
Sarah

[heartfulloflove]

To ease your mind, unless a person develops the acute infection version of CMV, the chances of it affecting the heart are really really really slim. The majority of the population (arounnd 80%) carries CMV by the age of 40 because most people are exposed at some point. Most who are will not get sick at all, or will develop a minor cold. The usual age for getting CMV is the preschool/young child. I managed to avoid it until my 20s, and I got the acute infection complete with liver and spleen enlargement. I have a funny feeling if someone would have done an echo, my heart may have been enlarged too, but I'm just guessing. It took me 6 months to recover, and I never did get my energy back completely.

The risks to a fetus when carried by a CMV+ mother is when the mother gets the acute infection while she is pregnant. Only about 1-4% of pregnant women get CMV for the first time while pregnant.

Soooo...unless your child has a weakened immune system or was born with a congential CMV infection (you would have known, for sure) the changes of this affecting their heart is really incredibly small.

I did some researching when I was pregnant with Gavin because I worried about the same things, but once I found some info I was much relieved. I hope this helps!

Check out the CDC site also, they have great info on it (though they don't mention the heart involvement).

http://www.cdc.gov/cmv/index.htm

[sfekke]

To ease your mind, unless a person develops the acute infection version of CMV, the chances of it affecting the heart are really really really slim. The majority of the population (arounnd 80%) carries CMV by the age of 40 because most people are exposed at some point. Most who are will not get sick at all, or will develop a minor cold. The usual age for getting CMV is the preschool/young child. I managed to avoid it until my 20s, and I got the acute infection complete with liver and spleen enlargement. I have a funny feeling if someone would have done an echo, my heart may have been enlarged too, but I'm just guessing. It took me 6 months to recover, and I never did get my energy back completely.

The risks to a fetus when carried by a CMV+ mother is when the mother gets the acute infection while she is pregnant. Only about 1-4% of pregnant women get CMV for the first time while pregnant.

Soooo...unless your child has a weakened immune system or was born with a congential CMV infection (you would have known, for sure) the changes of this affecting their heart is really incredibly small.

I did some researching when I was pregnant with Gavin because I worried about the same things, but once I found some info I was much relieved. I hope this helps!

Check out the CDC site also, they have great info on it (though they don't mention the heart involvement).

http://www.cdc.gov/cmv/index.htm

Hi Shannon,

Thanks for the response. I knew the data regarding CMV that 80% of adults carry antibodies for it and that it really only poses a danger to the fetus if you are infected for the first time while pregnant. However, with the blunting that goes on in pregnancy, or in an instance of a weakened immune system, if there is a re-emergence of CMV or any other cardiotropic virus that could by hypothesis cause PPCM, (I know this is not proven), then could our bodies have allowed this to pass along the umbilical cord?

The question I have is that there was something unknown going on in our bodies that caused this bizarre illness - it may remain a mystery for some time. But there have been a few women on this site with children that have heart trouble and one lady whose baby had seizures. I'm not trying to scare everyone because even if you are infected with CMV while pregnant the chances of it causing birth defects are still low, I think less than 10%. I'm not sure if its a given you would know if the baby was born infected with CMV.

When my son was a few days old, my pediatrician asked if a virus caused my heart trouble and I said no. Correct answer should have been, I'm not sure. There was something "not right" going on in my body, we don't know what for sure, so how can we know for sure if it impacted the baby.

Thanks,
Sarah

[christyh]

about 2 years before I developed PPCM, my brother was dx with DCM due to a virus. He is 18 months younger than I and thankfully both of us have much improved, he has been taken off the transplant list. I always found it interesting that we both have the same type of heart disease, each supposedly due to different causes.

[JAMESFETT]

Another very amazing observation in PPCM is that while the mother's heart is the primary target, the fetus' heart is spared totally. That's an immune phenom called "tolerization" which is better described by immunologist Sally Huber than by me. You really don't need to worry.

JDF

[heartfulloflove]

about 2 years before I developed PPCM, my brother was dx with DCM due to a virus. He is 18 months younger than I and thankfully both of us have much improved, he has been taken off the transplant list. I always found it interesting that we both have the same type of heart disease, each supposedly due to different causes.

That supports my hypothesis that several factors have to be involved.

Anyhow, Sarah - really awesome question, one I hadn't thought of yet! Dr. Fett's answer is very reassuring :D

[sfekke]

That supports my hypothesis that several factors have to be involved.

Anyhow, Sarah - really awesome question, one I hadn't thought of yet! Dr. Fett's answer is very reassuring :D

Ditto that -yes thanks so much Dr. Fett, again! It is reassuring and info I've been trying to get for some time.