title: Virus serology in patients with suspected myocarditis: utility or futility?
abstract: OBJECTIVE
  Serological analyses of viral infection in suspected myocarditis are still widely used, although convincing evidence for their value is lacking. We determined prospectively the diagnostic value of virus serology in comparison with endomyocardial biopsy (EMB) including viral genome detection and immunohistochemistry in patients with clinically suspected myocarditis.
  
  
  RESULTS
  Virus serology and state-of-the-art evaluation of EMB were performed in 124 patients (age 40 ± 15 years) with suspected myocarditis. Endomyocardial biopsy was studied for inflammation with histological and immunohistological criteria. The viral genome was detected in the myocardium by polymerase chain reaction. Acute viral infection with enterovirus, adenovirus, parvovirus B19, cytomegalovirus, human herpesvirus, and Epstein-Barr virus was diagnosed by IgM or IgA in the initial sample or IgG seroconversion in the follow-up sample. Immunohistological signs of inflammation were present in 54 patients. The viral genome was detected in the myocardium of 58 patients (47%). In 20 patients (16%), acute viral infection was diagnosed by serology. Only in 5 out of 124 patients (4%), there was serological evidence of an infection with the same virus that was detected by EMB. Sensitivity and specificity of virus serology were 9 and 77%, respectively. The positive predictive value was 25% and the negative predictive value was 49%. The lack of correlation between serology and EMB remained also for patients with biopsy-proven myocarditis and patients with time from initial symptoms to EMB procedure of ≤1 month.
  
  
  CONCLUSIONS
  For patients with suspected myocarditis, virus serology has no relevance for the diagnosis of myocardial infection. Endomyocardial biopsy remains the gold standard in the diagnostic of viral myocarditis.
authors.affiliation: Klinik für Innere Medizin III, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, Homburg/Saar, Germany. felix.mahfoud@uks.eu
authors.forename: Felix
authors.initials: F
authors.lastname: Mahfoud
authors.forename: Barbara
authors.initials: B
authors.lastname: Gärtner
authors.forename: Michael
authors.initials: M
authors.lastname: Kindermann
authors.forename: Christian
authors.initials: C
authors.lastname: Ukena
authors.forename: Katharina
authors.initials: K
authors.lastname: Gadomski
authors.forename: Karin
authors.initials: K
authors.lastname: Klingel
authors.forename: Reinhard
authors.initials: R
authors.lastname: Kandolf
authors.forename: Michael
authors.initials: M
authors.lastname: Böhm
authors.forename: Ingrid
authors.initials: I
authors.lastname: Kindermann
mesh_terms: D000328:Adult; D000914:Antibodies, Viral / Q000097:blood; D001706:Biopsy / Q000379:methods; D004279:DNA, Viral / Q000032:analysis; D004699:Endocardium / Q000473:pathology; D005260:Female; D016679:Genome, Viral; D006801:Humans; D007136:Immunoglobulins / Q000097:blood; D007150:Immunohistochemistry; D008297:Male; D018447:Medical Futility; D009205:Myocarditis / Q000175:diagnosis / Q000473:pathology / Q000821:virology*; D009206:Myocardium / Q000473:pathology*; D011446:Prospective Studies; D012367:RNA, Viral / Q000032:analysis; D020133:Reverse Transcriptase Polymerase Chain Reaction; D014773:Virology / Q000379:methods*; D014777:Virus Diseases / Q000175:diagnosis*; D055815:Young Adult
chemical_list: D000914:Antibodies, Viral; D004279:DNA, Viral; D007136:Immunoglobulins; D012367:RNA, Viral