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Virus-positive vs Virus-negative Myocarditis — EECC MCQ

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HardHeart FailureVirus-positive vs Virus-negative MyocarditisEECC

A 55-year-old woman with new-onset DCM (LVEF 20%) undergoes endomyocardial biopsy which shows active lymphocytic myocarditis with ongoing viral genome (parvovirus B19 positive by PCR). Should immunosuppressive therapy be initiated?

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Correct answer: B — Immunosuppression is not recommended in virus-positive myocarditis, as it may promote viral replication; antiviral strategies or watchful waiting with GDMT is preferred

The 2025 ESC Myocarditis/Pericarditis Guidelines distinguish between virus-positive and virus-negative inflammatory cardiomyopathy. In virus-positive myocarditis, immunosuppression is generally NOT recommended as it may facilitate viral replication and worsen outcomes. Treatment is supportive (GDMT for HF). Specific antiviral therapy (e.g. IV immunoglobulin for parvovirus B19, interferon-beta for enterovirus/adenovirus) may be considered at expert centres. In virus-negative lymphocytic myocarditis with ongoing inflammation, immunosuppressive therapy (prednisolone + azathioprine) may be considered based on the TIMIC trial. Endomyocardial biopsy with viral PCR is therefore essential to guide treatment.

Reference: ESC (2025): Guidelines for Myocarditis and Pericarditis