What is the best therapy to start for a patient with refractory viral myocarditis?

For a patient with refractory viral myocarditis, immunoglobulin therapy is often considered the best initial treatment option due to its mechanism of action and clinical evidence supporting its use. Immunoglobulin, specifically intravenous immunoglobulin (IVIG), works by modulating the immune response and has been shown to provide benefits in acute viral myocarditis. It helps neutralize viral particles, reduces inflammation, and assists in the recovery of heart function by enhancing the body’s immune response.

Clinical studies have indicated that early initiation of immunoglobulin therapy can lead to improved outcomes, particularly in patients who are experiencing significant symptoms or persistent hemodynamic instability, making it a compelling choice in cases of refractory myocarditis.

Other therapies listed, while they may have roles in managing various autoimmune conditions or inflammatory processes, are not first-line treatments specifically for viral myocarditis. For instance, corticosteroids like methylprednisolone can be useful in certain inflammatory conditions, but their use in viral myocarditis is more controversial and they may even be harmful in certain situations.

Cyclosporine and azathioprine, which are immunosuppressants, might be used in more chronic or autoimmune forms of myocarditis but are not typically first-line treatments for viral infections due to the risk