Unusual association of ST-T abnormalities, myocarditis and cardiomyopathy with H(1)N(1 )influenza in pregnancy: two case reports and review of the literature

INTRODUCTION: Myocarditis is rarely reported as an extra-pulmonary manifestation of influenza while pregnancy is a rare cause of cardiomyopathy. Pregnancy was identified as a major risk factor for increased mortality and morbidity due to H(1)N(1 )influenza in the pandemic of 2009 to 2010. However, to the best of our knowledge there are no previous reports in the literature linking H(1)N(1 )with myocarditis in pregnancy. CASE PRESENTATION: We report the cases of two pregnant Caucasian women (aged 29 and 30), with no pre-existing illness, presenting with respiratory manifestations of H(1)N(1 )influenza virus infection in their third trimester. Both women developed evidence of myocarditis. One woman developed acute respiratory distress syndrome, almost reaching the point of requiring extra-corporeal membrane oxygenation, and subsequently developed persistent cardiomyopathy; the other recovered without any long-term consequence. CONCLUSIONS: While it is not possible to ascertain retrospectively if myocarditis was caused by either infection with H(1)N(1 )virus or as a result of pregnancy (in the absence of endomyocardial biopsies), the significant association with myocardial involvement in both women demonstrates the increased risk of exposure to H(1)N(1 )influenza virus in pregnant women. This highlights the need for health care providers to increase awareness amongst caregivers to target this 'at risk' group aggressively with vaccination and prompt treatment.