Background: 
Myocarditis is a challenging disease due to the heterogeneous clinical manifestations andvarying aetiology.

Case Report: 
We hospitalised a 14-year-old febrile boy with chest pain, tachycardia and pharyngitis. Echocardiography (TTE) showed an ejection fraction (EF) of ≤ 60% and a mild mitral regurgitation (Fig. 1ac);troponin T was >50 ng/mL. The WBC and CRP were 27.5*103/mL and 282 mg/L, respectively. The blood cultures were negative, and PCT normal. His condition quickly worsened; he developed a pulmonary congestion, pleural and pericardial effusion (Fig. 1d-f) and his EF dropped to 40% with moderate mitral regurgitation. 
Treatment consisted of diuretics, ACE-inhibitors, β-blockers and antithrombotics, including prophylactic Ceftriaxone. The patient was placed on continuous venovenous hemodiafiltration using
cytokine-adsorbing Prismaflex oXiris filters (CVVHDF-CAH) at 35 mL/kg/hr. Azithromycin was included in the therapy at this stage; we replaced the hemofilters every 24 hr. 
Therapy improved the clinical condition within 48hr; troponin T decreased to 0.19 ng/mL. The patient was afebrile with improved cardiopulmonary parameters at discharge on day 8 (Fig. 1g-i). 
We reassessed the patient on day 15; he was in good condition, EF> 55% with a normal mitral profile.

Discussion:
Myocarditis is a rare and severe cardiac inflammatory disease. The endomyocardial biopsy is the gold standard diagnostic method, but it is infrequently used due to the risks. Treatment of myocarditis is primarily supportive [1].
Removal of pro-inflammatory mediators is an attractive approach to curb the disease progression. CVVHDF-CAH using Oxiris filter can efficiently eliminate inflammatory cytokines and chemokines, resolve pulmonary congestion, prevent acute renal failure and pulmonary oedema [2].

We administered prophylactic broad-spectrum antibiotics to reduce the risks of bacterial co-infections but delayed the inclusion of Azithromycin until the start of the CVVHDF-CAH due to its nephrotoxicity.

Learning points: 
CVVHDF-CAH using Oxiris filter is an attractive adjuvant therapy for Myocarditis.

References: 
1. Canter et al., Circulation 2014. 2. Turani et al., Critical Care 2013

06 / Continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters with Prismaflex oXiris filter for the treatment of Myocarditis