Heart Vessels (1992) 7:76-81
Heart
°dVessels
© Springer-Verlag1992
Intracardiac thrombus in murine coxsackievirus B3 myocarditis Chiharu Kishimoto 1, Hiroshi Ochiai 2, and Shigetake Sasayama 1 1The Second Department of Internal Medicine and 2Department of Virology, Faculty of Medicine, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930-01, Japan
Summary. We studied the appearance of intracardiac mural thrombi with time and the relationship between thrombosis and congestive heart failure (CHF) in murine coxsackievirus B3 (CB3) myocarditis. Fourto six-week-old C3H/He mice were inoculated intraperitoneally with CB3 and were observed for 90 days. Mice were sacrificed periodically on days 4, 8, 14, 30, and 90. Among 129 mice with myocarditis, 35 (27.1%) developed C H F and40 (31.0%) demonstrated thrombi after day 8. The total incidence of thrombosis was significantly higher in mice with C H F (71.4%; 25/35) than in those without CHF (16.0%; 15/94) (P < 0.001). The present study suggests that CB3 myocarditis carries a significant risk of thromboembolism, and that CHF is a risk factor for the appearance of thrombi. Key words: Acute myocarditis - Coxsackievirus B3 C3H/He Mice - Intracardiac thrombus Congestive heart failure
unexpected death [1-5]. However, little attention has been paid to the significance of intracardiac mural thrombosis as a complication of viral myocarditis
[6-81. Coxsackievirus B3 (CB3) is an enterovirus which can cause acute myocarditis in man. Recently, we found severe myocarditis caused by CB3 in various inbred strains of mice [9-11]. This animal model is now considered to be excellent for studying the pathogenesis of myocarditis [9-11]. In this study, we demonstrated the experimental production of mural thrombi in CB3 myocarditis in mice, and investigated the pathogenesis of thrombus formation and the relationship between thrombosis and congestive heart failure (CHF).
Methods
Experimental infections
Introduction Clinical manifestations of viral myocarditis comprise electrocardiographic abnormalities, enzymatic disorders, congestive heart failure, and even sudden
Address correspondence to: S. Sasayama This work was supported by research grants of the Japanese Heart Foundation, Education Fellowship of Toyama Medical and Pharmaceutical University, Iwaki Fellowship, Japanese Education of Science and Welfare (Nos. 01570478 and 03670445), and the Uehara Memorial Foundation Received November 13, 1990; revision received December 2, 1991; accepted December 6, 1991.
The Nancy strain of coxsackievirus B3 (CB3) was used; the virus stock was prepared in cultures of VERO (kidney of African green monkey) cells in Eagle's minimum essential medium. Virus suspensions were centrifuged after the cytopathic effect had developed. Virus stock had a titer of more than 10 9 plaque-forming units (PFU)/ml determined in tissue cultures of VERO cells. Virus fluid was stored at - 80°C until use.
Inbred C3H/He mice had been maintained continuously by brother-sister matings. At 4-6 weeks of age, mice were inoculated intraperitoneally with 0.1ml virus suspension containing 106 PFU/0.1 ml. The mice were observed daily, and 20-38 mice were sacrificed periodically on days 4, 8, 14, 30, and 90. After gross inspection of the heart for alterations of myocardial appearance, i.e., myocardial calcification, ascites or pleural effusion, the hearts and other organs were processed for histological or virological studies. Twenty mice were inoculated intraperitoneally with 0.1 ml saline, and 4 mice each were sacrificed on days 4, 8, 14, 30, and 90 (uninfected controls). The hearts were examined in the same manner as those of the infected mice.
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
77
Fig. 1. The right atrium on day 8. A fresh thrombus (TH) is evidenced by lamellae of platelets and nurnerous erythrocyte and leukocyte aggregates between the lamellae of platelets. H & E, x370
Pathological study Hearts were fixed in 10% formalin solution, sectioned longitudinally through the four chambers, embedded in paraffin, and stained with hematoxylin-eosin (H & E). The lungs, liver and other organs (thymus, spleen, pancreas, kidney and muscle) were also sectioned and stained with hematoxylin-eosin. Myocardial lesions, including myocardial necrosis, cellular infiltration, and calcification, were evaluated. Because of the recognized propensity of C3H/He mice for spontaneous dystrophic calcification of the right ventricle, this condition was not included in the analysis. Congestive heart failure (CHF) was determined by the presence of pleural effusion and ascites at autopsy, and the histological evidence of congestion of the lungs and liver. Among these criteria, at least one was needed to conclude that a mouse had CHF. To avoid the postmortem changes, the pathological study was performed only upon the sacrificed mice.
Virological study For infectivity assays, some hearts were removed aseptically, weighed, and homogenized in 2tal phosphate buffered saline. After centrifugation at 1,500rpm for 15min, virus titers in the ~upernatants were determined by the plaque assay method, as described previously [9-11].
Statistical analysis The chi-square test with Yates correction was used to determine the significance of differences in the incidence of CHF and thrombosis.
Results Four days after the CB3 inoculation, the mice appeared ill. Some developed coat ruffling, weakness, and irritability. Grossly, the myocardium showed pale
yellow patches that correlated with the inflammation, necrosis, and calcification seen microscopically. The incidence of myocarditis was 100%. None of the uninfected control mice had developed thrombi or myocardial lesions, except for spontaneous dystrophic calcification of the right ventricular wall.
Pathological findings Pale yellow patches were seen on the surface of the ventricles after day 4. On day 4, necrotic foci with cellular infiltration and interstitial edema appeared in the myocardium. On day 8, mural thrombi appeared in the atria and ventricles (Figs. 1, 2). Early fresh thrombi consisted of platelets forming coral-like structures with entrapped erythrocytes and leukocytes (Figs. 1, 2). Thereafter, myocardial necrosis became more extensive, and cellular infiltration was most prominent on day 14. After day 8, dilatation of the ventricles developed and fine endothelium appeared on the surface of the thrombi (Fig. 2). Pleural effusion, ascites, and congestion of the lungs and liver (Fig. 3) were noted and death was due to congestive heart failure; histologically, dilatation of the central vein in the liver, and interstitial edema, diffuse alveolar damage, and increased alveolar exudates in the lungs were seen. Some mice with CHF showed so-called heart failure cells in the alveolar space. On day 14, myocardial lesions were prominent in subendocardial regions. The endomyocardium at the site of attachment of the thrombus showed muscle necrosis and cellular infiltration. On day 30, successive layers were laid down and large thrombi filled the chambers (Fig. 4). On days 30 and 90, cellular infiltration was diminished, but myocardial calcification persisted.
78
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 rnyocarditis
Fig. 2. a The right ventricle on day 8. Aneurysmal dilatation of the right ventricular cavity (arrow). Thrombi are seen in both ventricles. H & E, x80. b Higher magnification of a. A thrombus (TH) is located at the site of myocardial lesions. Arrowheads indicate the fine endothelium on the surface of the thrombus. H & E, x370
Myocardial fibrosis was evident in these periods; calcified and organized multiple thrombi were also documented in this period (Fig. 5).
The total incidence of thrombosis in mice with CHF was significantly higher than in mice withou,t CHF (P < 0.001).
Relationship between thrombosis and CHF
Virus isolation
Thrombi were found in 15 out of 94 mice without CHF (16.0%). The incidence of thrombosis on days 4, 8, 14, 30, and 90 in mice without CHF was 0.0%, 11.8%, 15.4%, 20.0%, and 46.7%, respectively. Thrombi were noted in 25 out of 35 mice with CHF (71.4%): the incidence of coexistence on days 4, 8, 14, 30, and 90 was 0.0%, 66.7%, 66.7%, 66.7% and 100%, respectively. There was a significant difference between the incidence of thrombosis in mice with CHF on day 14 and that in mice without CHF (P < 0.01).
Virus was isolated ffom the hearts of all 5 mice examined on day 4, from the hearts of 3 of 6 mice on day 8 and from none of 6 on day 14.
Discussion In myocardial infarction, left ventricular thrombi were found soon after the onset of infarction [12]. Little information, however, is available on the time course
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
79
Fig. 3. a Congestion of tiver is found after day 8. H & E, ×370. b Congestion of lung is also seen. H & E, x370
of intracardiac thronabus formation in viral myocarditis [6-8]. Previously, Reyes and colleagues [13] observed that 7 out of 54 (13.0%) ICD Swiss mice forced to swim during the first 9 days of infection had atrial thrombi 15 months after CB3 inoculation. In this study, we found a high incidence of mural thrombi in C3H/He mice with CHF caused by CB3 myocarditis. We found no mural thrombi on day 4. The earliest fresh thrombi were observed on day 8. A pathological study revealed no relationship between the severity of myocarditis and the incidence of thrombosis. Our data support the opinion that thrombosis in myocarditis is initiated by endomyocardial damage [14], and may persist during the chronic stage. In other words, not the severe
myocardial lesion but the injury of the endomyocardium is the decisive event leading to thrombus formation in CB3 myocarditis. A significant higher incidence of thrombosis was shown in mice with CHF. This indicates that the endocardial lesion and the cardiac dilatation, i.e., the change of stasis of the blood flow, are factors in the pathogenetic process of the thrombus formation in CB3 myocarditis. In particular, CHF may be closely related to the thrombus formation. According to the relationship between thrombosis and CHF, Daly et al. [15] reported that 2 of their 5 patients with thromboembolism had normal left ventricular dimensions. In cases published by Obeyesekere and Hermony [16], embolism occurred when the left
80
C. Kishimoto, et al. : Thrombosis in coxsackievirus B3 myocarditis ventricular function was normal. Clinically, thrombi are formed in all cavities of the heart in acute viral myocarditis. In autopsy cases, thrombi were found in the right and left atrial appendages and the apices of both ventricles [6]. In CB3 myocarditis, an initial endomyocardial injury caused by the virus amplification may be a trigger for thrombus formation. Congestive heart failure due to cardiac damage may be a promoting factor. It is important, however, to recognize that intracardiac mural thrombi develop during the early stage of CB3 myocarditis. Thus, to prevent the thrombus formation in CB3 myocarditis, early anticoagulant therapy may be considered even in the asymptomatic or early stage of the disease.
References
Fig. 4. The left atrium on day 30. A large thrombus (TH) is seen filling the chamber. H & E, x20
1. Reyes M. Lerner AM (1985) Coxsackievirus myocarditis: With special reference to acute and chronic effects. Prog Cardiovasc Dis 27:373-394 2. Abelmann WH (1973) Viral myocarditis and its sequelae. Ann Rev Med 24:145-152 3. Lerner AM. Wilson FM (1973) Virus myocardiomyopathy. Prog Med Viol 15:63-91 4. Kawai C, Matsumori A, Kitaura Y, Takatsu T (1978) Viruses and the heart: Vital myocarditis and cardiomyopathy. Prog Cardiol 7:141-162 5. Woodruff JF (1980) Viral myocarditis. A review. Am J Pathol 101:427-479 6. Sanyol SK, Mahdavy M, Gabrielson MO, Vidone RA, Browne MJ (1965) Fatal myocarditis in an adolescent caused by coxsackievirus, group B, type four. Pediatrics 35:36-41 7. Desa'neto A, Bullington JD, Bullington RH, Dessor KB, Benchimol A (1980) Coxsackie B5 heart disease:
Fig. 5. The heart on day 90. There are calcified multiple thrombi (TH) in both atria. IVS, Interventricular septum, LV, left ventricle, RV, right ventricle. H & E , x14
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
8. 9.
10.
11.
Demonstration of inferolateral wall myocardial necrosis. Am J Med 68:295-298 Melvin K, Richardson PJ, Olsen EGJ, Daly K, Jackson G (1982) Peripartum cardiomyopathy due to myocarditis. N Engl J Med 307:731-734 Kishimoto C, Kawai C, Abelmann WH (1987) Immunogenetic aspects of the pathogenesis of experimental viral myocarditis. In: Kawai C, Abelmann WH (eds) Cardiomyopathy 1987. Pathogenesis of myocarditis and cardiomyopathy. Experimental and clinical studies. University of Tokyo Press, Tokyo, pp 3 - 7 Kishimoto C, Misaki T, Crumpacker CS, Abelmann WH (1988) Serial immunological identification of lymphocyte subsets in murine coxsackie B3 myocarditis. Different kinetics and significance of lymphocyte subsets in heart a~d in peripheral blood. Circulation 77:645653 Kishimoto C, Abelmann WH (1989) Absence of effect of cyclosperine on myocardial lymphocyte subsets in
12. 13. 14. 15.
16.
81 coxsackievirus B3 myocarditis in the aviremic stage. Circ Res 65:934-945 Asinger RW, Mikell FL, Hodges M (1981) Incidence of left ventricular thrombosis after transmural myocardial infarction. N Engl J Med 305:297-302 Reyes MP, Ho KL, Smith F, Lerner AM (1981) A mouse model of dilated-typè cardiomyopathy due to coxsackie virus B3. J Infect Dis 144:232-236 Carter G, Gavin JB (1986) Morphological changes in endocardium subjected to global ischemia. Basic Res Cardiol 81:465-472 Daly K, Monaghan M, Richardson P, Jackson G, Jewitt DE (1983) Significant incidence of mural thrombi in acute myocarditis - Indication for early anticoagulation (abstract). J Am Coll Cardiol 1:584 Obeyesekere I, Hermony Y (1973) Arbovirus heart disease: Myocarditis and cardiomyopathy following dengue and chikungunya fever. A follow up study. Am Heart J 85:186-194
Heart
°dVessels
© Springer-Verlag1992
Intracardiac thrombus in murine coxsackievirus B3 myocarditis Chiharu Kishimoto 1, Hiroshi Ochiai 2, and Shigetake Sasayama 1 1The Second Department of Internal Medicine and 2Department of Virology, Faculty of Medicine, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930-01, Japan
Summary. We studied the appearance of intracardiac mural thrombi with time and the relationship between thrombosis and congestive heart failure (CHF) in murine coxsackievirus B3 (CB3) myocarditis. Fourto six-week-old C3H/He mice were inoculated intraperitoneally with CB3 and were observed for 90 days. Mice were sacrificed periodically on days 4, 8, 14, 30, and 90. Among 129 mice with myocarditis, 35 (27.1%) developed C H F and40 (31.0%) demonstrated thrombi after day 8. The total incidence of thrombosis was significantly higher in mice with C H F (71.4%; 25/35) than in those without CHF (16.0%; 15/94) (P < 0.001). The present study suggests that CB3 myocarditis carries a significant risk of thromboembolism, and that CHF is a risk factor for the appearance of thrombi. Key words: Acute myocarditis - Coxsackievirus B3 C3H/He Mice - Intracardiac thrombus Congestive heart failure
unexpected death [1-5]. However, little attention has been paid to the significance of intracardiac mural thrombosis as a complication of viral myocarditis
[6-81. Coxsackievirus B3 (CB3) is an enterovirus which can cause acute myocarditis in man. Recently, we found severe myocarditis caused by CB3 in various inbred strains of mice [9-11]. This animal model is now considered to be excellent for studying the pathogenesis of myocarditis [9-11]. In this study, we demonstrated the experimental production of mural thrombi in CB3 myocarditis in mice, and investigated the pathogenesis of thrombus formation and the relationship between thrombosis and congestive heart failure (CHF).
Methods
Experimental infections
Introduction Clinical manifestations of viral myocarditis comprise electrocardiographic abnormalities, enzymatic disorders, congestive heart failure, and even sudden
Address correspondence to: S. Sasayama This work was supported by research grants of the Japanese Heart Foundation, Education Fellowship of Toyama Medical and Pharmaceutical University, Iwaki Fellowship, Japanese Education of Science and Welfare (Nos. 01570478 and 03670445), and the Uehara Memorial Foundation Received November 13, 1990; revision received December 2, 1991; accepted December 6, 1991.
The Nancy strain of coxsackievirus B3 (CB3) was used; the virus stock was prepared in cultures of VERO (kidney of African green monkey) cells in Eagle's minimum essential medium. Virus suspensions were centrifuged after the cytopathic effect had developed. Virus stock had a titer of more than 10 9 plaque-forming units (PFU)/ml determined in tissue cultures of VERO cells. Virus fluid was stored at - 80°C until use.
Inbred C3H/He mice had been maintained continuously by brother-sister matings. At 4-6 weeks of age, mice were inoculated intraperitoneally with 0.1ml virus suspension containing 106 PFU/0.1 ml. The mice were observed daily, and 20-38 mice were sacrificed periodically on days 4, 8, 14, 30, and 90. After gross inspection of the heart for alterations of myocardial appearance, i.e., myocardial calcification, ascites or pleural effusion, the hearts and other organs were processed for histological or virological studies. Twenty mice were inoculated intraperitoneally with 0.1 ml saline, and 4 mice each were sacrificed on days 4, 8, 14, 30, and 90 (uninfected controls). The hearts were examined in the same manner as those of the infected mice.
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
77
Fig. 1. The right atrium on day 8. A fresh thrombus (TH) is evidenced by lamellae of platelets and nurnerous erythrocyte and leukocyte aggregates between the lamellae of platelets. H & E, x370
Pathological study Hearts were fixed in 10% formalin solution, sectioned longitudinally through the four chambers, embedded in paraffin, and stained with hematoxylin-eosin (H & E). The lungs, liver and other organs (thymus, spleen, pancreas, kidney and muscle) were also sectioned and stained with hematoxylin-eosin. Myocardial lesions, including myocardial necrosis, cellular infiltration, and calcification, were evaluated. Because of the recognized propensity of C3H/He mice for spontaneous dystrophic calcification of the right ventricle, this condition was not included in the analysis. Congestive heart failure (CHF) was determined by the presence of pleural effusion and ascites at autopsy, and the histological evidence of congestion of the lungs and liver. Among these criteria, at least one was needed to conclude that a mouse had CHF. To avoid the postmortem changes, the pathological study was performed only upon the sacrificed mice.
Virological study For infectivity assays, some hearts were removed aseptically, weighed, and homogenized in 2tal phosphate buffered saline. After centrifugation at 1,500rpm for 15min, virus titers in the ~upernatants were determined by the plaque assay method, as described previously [9-11].
Statistical analysis The chi-square test with Yates correction was used to determine the significance of differences in the incidence of CHF and thrombosis.
Results Four days after the CB3 inoculation, the mice appeared ill. Some developed coat ruffling, weakness, and irritability. Grossly, the myocardium showed pale
yellow patches that correlated with the inflammation, necrosis, and calcification seen microscopically. The incidence of myocarditis was 100%. None of the uninfected control mice had developed thrombi or myocardial lesions, except for spontaneous dystrophic calcification of the right ventricular wall.
Pathological findings Pale yellow patches were seen on the surface of the ventricles after day 4. On day 4, necrotic foci with cellular infiltration and interstitial edema appeared in the myocardium. On day 8, mural thrombi appeared in the atria and ventricles (Figs. 1, 2). Early fresh thrombi consisted of platelets forming coral-like structures with entrapped erythrocytes and leukocytes (Figs. 1, 2). Thereafter, myocardial necrosis became more extensive, and cellular infiltration was most prominent on day 14. After day 8, dilatation of the ventricles developed and fine endothelium appeared on the surface of the thrombi (Fig. 2). Pleural effusion, ascites, and congestion of the lungs and liver (Fig. 3) were noted and death was due to congestive heart failure; histologically, dilatation of the central vein in the liver, and interstitial edema, diffuse alveolar damage, and increased alveolar exudates in the lungs were seen. Some mice with CHF showed so-called heart failure cells in the alveolar space. On day 14, myocardial lesions were prominent in subendocardial regions. The endomyocardium at the site of attachment of the thrombus showed muscle necrosis and cellular infiltration. On day 30, successive layers were laid down and large thrombi filled the chambers (Fig. 4). On days 30 and 90, cellular infiltration was diminished, but myocardial calcification persisted.
78
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 rnyocarditis
Fig. 2. a The right ventricle on day 8. Aneurysmal dilatation of the right ventricular cavity (arrow). Thrombi are seen in both ventricles. H & E, x80. b Higher magnification of a. A thrombus (TH) is located at the site of myocardial lesions. Arrowheads indicate the fine endothelium on the surface of the thrombus. H & E, x370
Myocardial fibrosis was evident in these periods; calcified and organized multiple thrombi were also documented in this period (Fig. 5).
The total incidence of thrombosis in mice with CHF was significantly higher than in mice withou,t CHF (P < 0.001).
Relationship between thrombosis and CHF
Virus isolation
Thrombi were found in 15 out of 94 mice without CHF (16.0%). The incidence of thrombosis on days 4, 8, 14, 30, and 90 in mice without CHF was 0.0%, 11.8%, 15.4%, 20.0%, and 46.7%, respectively. Thrombi were noted in 25 out of 35 mice with CHF (71.4%): the incidence of coexistence on days 4, 8, 14, 30, and 90 was 0.0%, 66.7%, 66.7%, 66.7% and 100%, respectively. There was a significant difference between the incidence of thrombosis in mice with CHF on day 14 and that in mice without CHF (P < 0.01).
Virus was isolated ffom the hearts of all 5 mice examined on day 4, from the hearts of 3 of 6 mice on day 8 and from none of 6 on day 14.
Discussion In myocardial infarction, left ventricular thrombi were found soon after the onset of infarction [12]. Little information, however, is available on the time course
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
79
Fig. 3. a Congestion of tiver is found after day 8. H & E, ×370. b Congestion of lung is also seen. H & E, x370
of intracardiac thronabus formation in viral myocarditis [6-8]. Previously, Reyes and colleagues [13] observed that 7 out of 54 (13.0%) ICD Swiss mice forced to swim during the first 9 days of infection had atrial thrombi 15 months after CB3 inoculation. In this study, we found a high incidence of mural thrombi in C3H/He mice with CHF caused by CB3 myocarditis. We found no mural thrombi on day 4. The earliest fresh thrombi were observed on day 8. A pathological study revealed no relationship between the severity of myocarditis and the incidence of thrombosis. Our data support the opinion that thrombosis in myocarditis is initiated by endomyocardial damage [14], and may persist during the chronic stage. In other words, not the severe
myocardial lesion but the injury of the endomyocardium is the decisive event leading to thrombus formation in CB3 myocarditis. A significant higher incidence of thrombosis was shown in mice with CHF. This indicates that the endocardial lesion and the cardiac dilatation, i.e., the change of stasis of the blood flow, are factors in the pathogenetic process of the thrombus formation in CB3 myocarditis. In particular, CHF may be closely related to the thrombus formation. According to the relationship between thrombosis and CHF, Daly et al. [15] reported that 2 of their 5 patients with thromboembolism had normal left ventricular dimensions. In cases published by Obeyesekere and Hermony [16], embolism occurred when the left
80
C. Kishimoto, et al. : Thrombosis in coxsackievirus B3 myocarditis ventricular function was normal. Clinically, thrombi are formed in all cavities of the heart in acute viral myocarditis. In autopsy cases, thrombi were found in the right and left atrial appendages and the apices of both ventricles [6]. In CB3 myocarditis, an initial endomyocardial injury caused by the virus amplification may be a trigger for thrombus formation. Congestive heart failure due to cardiac damage may be a promoting factor. It is important, however, to recognize that intracardiac mural thrombi develop during the early stage of CB3 myocarditis. Thus, to prevent the thrombus formation in CB3 myocarditis, early anticoagulant therapy may be considered even in the asymptomatic or early stage of the disease.
References
Fig. 4. The left atrium on day 30. A large thrombus (TH) is seen filling the chamber. H & E, x20
1. Reyes M. Lerner AM (1985) Coxsackievirus myocarditis: With special reference to acute and chronic effects. Prog Cardiovasc Dis 27:373-394 2. Abelmann WH (1973) Viral myocarditis and its sequelae. Ann Rev Med 24:145-152 3. Lerner AM. Wilson FM (1973) Virus myocardiomyopathy. Prog Med Viol 15:63-91 4. Kawai C, Matsumori A, Kitaura Y, Takatsu T (1978) Viruses and the heart: Vital myocarditis and cardiomyopathy. Prog Cardiol 7:141-162 5. Woodruff JF (1980) Viral myocarditis. A review. Am J Pathol 101:427-479 6. Sanyol SK, Mahdavy M, Gabrielson MO, Vidone RA, Browne MJ (1965) Fatal myocarditis in an adolescent caused by coxsackievirus, group B, type four. Pediatrics 35:36-41 7. Desa'neto A, Bullington JD, Bullington RH, Dessor KB, Benchimol A (1980) Coxsackie B5 heart disease:
Fig. 5. The heart on day 90. There are calcified multiple thrombi (TH) in both atria. IVS, Interventricular septum, LV, left ventricle, RV, right ventricle. H & E , x14
C. Kishimoto, et al.: Thrombosis in coxsackievirus B3 myocarditis
8. 9.
10.
11.
Demonstration of inferolateral wall myocardial necrosis. Am J Med 68:295-298 Melvin K, Richardson PJ, Olsen EGJ, Daly K, Jackson G (1982) Peripartum cardiomyopathy due to myocarditis. N Engl J Med 307:731-734 Kishimoto C, Kawai C, Abelmann WH (1987) Immunogenetic aspects of the pathogenesis of experimental viral myocarditis. In: Kawai C, Abelmann WH (eds) Cardiomyopathy 1987. Pathogenesis of myocarditis and cardiomyopathy. Experimental and clinical studies. University of Tokyo Press, Tokyo, pp 3 - 7 Kishimoto C, Misaki T, Crumpacker CS, Abelmann WH (1988) Serial immunological identification of lymphocyte subsets in murine coxsackie B3 myocarditis. Different kinetics and significance of lymphocyte subsets in heart a~d in peripheral blood. Circulation 77:645653 Kishimoto C, Abelmann WH (1989) Absence of effect of cyclosperine on myocardial lymphocyte subsets in
12. 13. 14. 15.
16.
81 coxsackievirus B3 myocarditis in the aviremic stage. Circ Res 65:934-945 Asinger RW, Mikell FL, Hodges M (1981) Incidence of left ventricular thrombosis after transmural myocardial infarction. N Engl J Med 305:297-302 Reyes MP, Ho KL, Smith F, Lerner AM (1981) A mouse model of dilated-typè cardiomyopathy due to coxsackie virus B3. J Infect Dis 144:232-236 Carter G, Gavin JB (1986) Morphological changes in endocardium subjected to global ischemia. Basic Res Cardiol 81:465-472 Daly K, Monaghan M, Richardson P, Jackson G, Jewitt DE (1983) Significant incidence of mural thrombi in acute myocarditis - Indication for early anticoagulation (abstract). J Am Coll Cardiol 1:584 Obeyesekere I, Hermony Y (1973) Arbovirus heart disease: Myocarditis and cardiomyopathy following dengue and chikungunya fever. A follow up study. Am Heart J 85:186-194
