A Novel Evaluation Indicator for Pediatric Fulminant Myocarditis: Diagnostic and Prognostic Value of the HALP Score

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Current diagnostic approaches primarily rely on cardiac function and myocardial injury markers, which fail to comprehensively assess the associated systemic inflammation and immune dysregulation. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score, a composite index integrating hemoglobin(Hb), albumin (Alb), lymphocyte count (Lym), and platelet count (Plt), offers a new perspective for evaluating the severity of pediatric fulminant myocarditis. Objective : To evaluate the diagnostic and prognostic utility of the HALP score in pediatric patients with fulminant myocarditis. Methods : This retrospective study included 71 children with myocarditis (22 with FM, 49 with non-fulminant myocarditis [NFM]). The HALP score was calculated from admission laboratory parameters (Hb × Alb × Lym / Plt). Its diagnostic performance was assessed via receiver operating characteristic (ROC) curve analysis. Associations with clinical outcomes (Pediatric Intensive Care Unit [PICU] admission, mechanical ventilation, vasoactive drug use) were analyzed. Independent predictors of FM were identified using multivariate logistic regression. Results : The median HALP score was significantly lower in the FM group compared to the NFM group (27.06 vs. 50.22, P =0.005). The HALP score had an area under the ROC curve (AUC) of 0.724 for diagnosing FM, with an optimal cutoff of 36.07 (sensitivity 77.6%, specificity 68.2%). Based on this cutoff, children in the low-HALP group (<36.07, n=26) had significantly higher rates of mechanical ventilation (30.77% vs. 6.67%, P =0.014), PICU admission (69.23% vs. 15.56%, P <0.001), and vasoactive drug use (61.54% vs. 15.56%, P <0.001) compared to the high-HALP group (≥36.07, n=45). Multivariate analysis confirmed that a lower HALP score ( OR =0.936, 95% CI : 0.885-0.991, P =0.023), along with elevated high-sensitivity troponin I (hs-cTnI) ( OR =1.106, 95% CI : 1.017-1.196, P =0.011) and reduced left ventricular ejection fraction (LVEF) ( OR =0.911, 95% CI : 0.856-0.970, P =0.003), were independent risk factors for FM. Conclusion : The HALP score, a simple composite index derived from routine blood tests, demonstrates significant value for the diagnosis, severity stratification, and prognosis prediction of pediatric fulminant myocarditis. It serves as a useful adjunct to conventional cardiac markers and may aid in early identification of high-risk patients requiring intensive care. Children Fulminant myocarditis HALP score Diagnosis Prognosis Figures Figure 1 Introduction Fulminant myocarditis (FM) represents one of the most critical and life-threatening conditions in pediatric cardiology. It is marked by abrupt onset and rapid progression, often leading to severe heart failure, malignant arrhythmias, cardiogenic shock, or sudden death, with a notably high mortality rate [ 1 ]. Early and accurate identification of FM, along with timely assessment of its severity, is essential for initiating effective life-support measures and improving clinical outcomes. Current diagnostic approaches largely depend on clinical manifestations, electrocardiographic changes, elevated myocardial injury biomarkers, and echocardiographic evidence of cardiac dysfunction [ 2 ]. However, these conventional indicators offer limited insight into the systemic inflammatory response, immune dysregulation, and multi-organ involvement characteristic of the disease. Emerging evidence highlights the central role of systemic inflammation and immune imbalance in the pathogenesis and progression of FM [ 3 ]. Consequently, identifying biomarkers that comprehensively reflect the body's inflammatory, nutritional, and immune status has become a key focus in refining risk stratification strategies for FM. The HALP score—a novel composite index derived from Hb, Alb, lymphocyte count (Lym), and platelet count (Plt)---provides an integrated perspective on a patient's systemic inflammation-nutrition-immunity profile [ 4 ]. This score has demonstrated prognostic utility across various clinical settings, including solid tumors [ 5 ], sepsis [ 6 ], and adult cardiovascular diseases [ 7 , 8 ]. Nevertheless, its application in pediatric fulminant myocarditis remains largely unexplored. Therefore, this study aims to systematically evaluate the diagnostic and prognostic value of the HALP score in pediatric FM through a retrospective analysis of clinical data from children with myocarditis treated at our institution over the past decade. The objective is to establish a simple, practical tool to aid in the early identification of high-risk patients and to support optimized therapeutic decision-making in clinical practice. Materials and Methods 1.1 Study Population This single-center retrospective study consecutively included 71 pediatric patients diagnosed with myocarditis and admitted to our center between January 1, 2013, and December 31, 2025, through the hospital electronic medical record system. 1.2 Diagnostic Criteria Myocarditis diagnosis was based on the 2020 American Heart Association scientific statement, "Recognition and Initial Management of Fulminant Myocarditis" [ 9 ], incorporating clinical manifestations, elevated myocardial injury markers, electrocardiographic abnormalities, echocardiographic evidence of cardiac structural and/or functional impairment, and exclusion of other definitive etiologies. Fulminant myocarditis (FM) was diagnosed according to established consensus criteria [ 10 ], requiring: (1) acute onset; (2) rapid clinical deterioration, typically progressing to severe heart failure, cardiogenic shock, or malignant arrhythmias within two weeks of symptom onset; and (3) need for advanced life support, including inotropic therapy, mechanical ventilation, or mechanical circulatory support. 1.3 Grouping Patients were stratified into a fulminant myocarditis group (FM group) and a non-fulminant myocarditis group (NFM group) based on the above criteria. 1.4 Exclusion Criteria Exclusion criteria comprised: (1) congenital heart disease; (2) known chronic cardiac conditions; (3) autoimmune diseases, malignancies, or severe hepatic or renal dysfunction; (4) severe anemia; (5) severe malnutrition; (6) hemorrhagic disorders; and (7) significantly incomplete clinical data. 1.5 Data Collection Two trained researchers independently extracted and cross-verified the following information from the electronic medical records: (1) General information: age and sex. (2) Clinical symptoms and signs at admission: precordial discomfort, fever, Adams-Stokes attacks, altered consciousness, dyspnea, nausea/vomiting, muffled heart sounds, arrhythmia, etc. (3) Laboratory parameters: results from the first venous blood test within 24 hours of admission, including white blood cell (WBC) count, C-reactive protein (CRP), high-sensitivity troponin I (hs-cTnI), creatine kinase-MB (CK-MB), Alb, Hb, absolute lymphocyte count, and Plt. (4) Imaging and electrocardiographic findings: results of the initial post-admission echocardiogram (left ventricular ejection fraction [LVEF], interventricular septal/ventricular wall motion, pericardial effusion, left ventricular enlargement) and electrocardiogram (ST-T segment changes, arrhythmias, etc.). (5) Treatment and clinical outcomes: admission to the Pediatric Intensive Care Unit (PICU), use of mechanical ventilation, administration of vasoactive drugs, and in-hospital mortality. Prognosis was defined as either death during hospitalization or survival to discharge. 1.6 HALP Score Calculation The HALP score was calculated using the formula[ 11 ]: HALP = Hb (g/L) × Alb (g/L) × Lym (×10 9 /L) / Plt (×10 9 /L). All component values were obtained from the first laboratory test performed at admission. 1.7 Statistical Analysis All statistical analyses were conducted using SPSS software, version 26.0. Continuous variables following a normal distribution were expressed as mean ± standard deviation and compared between groups using the independent samples t -test. Continuous variables not conforming to a normal distribution were reported as median (interquartile range) and compared using the Mann–Whitney U test. Categorical variables were described as numbers (percentages) and compared using the chi-square test or Fisher's exact test, as appropriate. Receiver operating characteristic (ROC) curves were constructed to evaluate the diagnostic performance of different indicators for fulminant myocarditis. Based on the optimal cut-off value of the HALP score, patients were stratified into low-HALP and high-HALP groups, and differences in clinical outcomes between the two groups were compared. Variables showing a P -value < 0.1 in univariate analysis were included in a multivariate logistic regression model to identify independent predictors of fulminant myocarditis. All statistical tests were two-sided, with P < 0.05 considered statistically significant. Results 2.1 Comparison of Baseline Characteristics and Clinical Features between Groups No statistically significant differences were observed in age, sex distribution, or clinical manifestations between the FM group and the NFM group (all P > 0.05). Details are presented in Table 1 . Table 1 Comparison of Baseline Characteristics and Clinical Manifestations between the Fulminant Myocarditis Group and the Non-Fulminant Myocarditis Group Variable Non-Fulminant Group (n = 49) Fulminant Group (n = 22) Z / χ² P Age [years, M (IQR)] 9.10 (4.75, 11.95) 8.25 (5.03, 9.20) -1.032 0.302 Male [n (%)] 33 (67.35) 10 (45.45) 3.047 0.081 Precordial Discomfort [n (%)] 28 (57.14) 9 (40.91) 1.612 0.204 Fever [n (%)] 21 (42.86) 11 (50.00) 0.315 0.575 Nausea/Vomiting [n (%)] 14 (28.57) 9 (40.91) 1.055 0.304 Abdominal Pain [n (%)] 8 (16.33) 6 (27.27) 1.149 0.284 Adams-Stokes Attack [n (%)] 2 (4.08) 4 (18.18) - 0.070* Arrhythmia [n (%)] 11 (22.45) 9 (40.91) 2.557 0.11 Note: *Fisher's exact test was used. 2.2 Comparison of Laboratory and Imaging Indicators between Groups Compared to the NFM group, patients in the FM group exhibited more pronounced inflammatory activation and myocardial injury. Levels of hs-cTnI and CK-MB were significantly elevated in the FM group (both P < 0.001), whereas Alb levels and the HALP score were markedly lower (both P 0.05). The LVEF was significantly reduced in the FM group, and the proportion of patients with diminished interventricular septum/ventricular wall motion was significantly higher compared to the NFM group (both P < 0.01). Detailed results are shown in Table 2 . Table 2 Comparison of Laboratory and Imaging Indicators between the Fulminant Myocarditis Group and the Non-Fulminant Myocarditis Group Variable Non-Fulminant Group (n = 49) Fulminant Group (n = 22) Z / χ² P WBC Count (×10⁹/L) 9.17 (6.43, 11.10) 9.65(7.78, 15.82) -1.598 0.110 CRP (mg/L) 2.77(0.69, 14.38) 11.81(1.24, 47.01) -1.604 0.109 hs-cTnI (µg/L) 0.02 (0.01, 1.04) 20.10 (2.50, 50.00) -4.726 < 0.001 CK-MB (U/L) 29.00 (19.50, 45.00) 66.50 (40.50, 120.25) -3.868 < 0.001 Creatinine (µmol/L) 44.00(34.00, 57.50) 47.00(38.75, 58.25) -0.606 0.538 Alb (g/L) 44.20 (40.00, 46.10) 37.55 (38.88, 42.33) -4.284 < 0.001 HALP Score 50.22 (37.08, 65.25) 27.06 (24.95, 49.91) -2.81 0.005 Hb (g/L) 129(118, 135.5) 125.5(108.5, 133.25) -1.4 0.162 Lym Count (×10 9 /L) 2.51 (1.71, 3.50) 1.73 (1.41, 2.23) -1.455 0.146 Plt Count (×10 9 /L) 270.00 (241.50, 356.50) 249.50 (181.50, 316.50) -1.847 0.065 LVEF (%) 66.00 (63.00, 69.00) 47.50 (32.50, 56.50) -4.439 < 0.001 Diminished Interventricular Septum / Ventricular Wall Motion [n(%)] 5 (10.20) 9 (40.91) 9.043 0.003 Pericardial Effusion [n (%)] 4 (8.16) 6 (27.27) - 0.060* Left Ventricular Enlargement [n (%)] 6 (12.24) 5 (22.73) 1.268 0.26 Note WBC: White Blood Cell; CRP: C-Reactive Protein; hs-cTnI: High-Sensitivity Troponin I; CK-MB: Creatine Kinase-MB; Alb: Albumin; HALP Score:hemoglobin, albumin, lymphocyte, and platelet score; Hb:Hemoglobin; CK-MB: creatine kinase-MB; Lym: Lymphocyte; Plt: Platelet; LVEF: Left Ventricular Ejection Fraction; *Fisher's exact test was used. 2.3 Diagnostic Value of the HALP Score and Other Indicators for Fulminant Myocarditis ROC curve analysis showed that high-sensitivity troponin I had the highest diagnostic efficacy for FM (AUC = 0.865), followed by left ventricular ejection fraction (AUC = 0.831). The AUC of the HALP score was 0.724 (95% CI : 0.593–0.856), with an optimal cutoff value of 36.07, yielding a sensitivity of 77.6% and specificity of 68.2%. See Table 3 . The DeLong test showed no statistically significant difference between the AUC of the HALP score and LVEF ( P = 0.308). Table 3 Results of ROC Curve Analysis for Diagnosing Fulminant Myocarditis Using Various Indicators Indicators AUC (95% CI ) P Optimal Cut-off Value Sensitivity (%) Specificity (%) Youden Index hs-cTnI 0.865 (0.770–0.959) < 0.001 12 µg/L 68.2 93.9 0.621 LVEF 0.831 (0.708–0.956) < 0.001 58.50% 87.8 81.8 0.696 HALP Score 0.724 (0.593–0.856) 0.001 36.07 77.6 68.2 0.458 Note AUC: area under the ROC curve; hs-cTnI: High-Sensitivity Troponin I; LVEF: Left Ventricular Ejection Fraction; HALP Score: hemoglobin, albumin, lymphocyte, and platelet score. A B Figure 1 (A) ROC curves assessing the predictive value of the HALP score and left ventricular ejection fraction for fulminant myocarditis;(B) ROC curve assessing the predictive value of high-sensitivity troponin I for fulminant myocarditis. 2.4 Association of HALP Score with Clinical Outcomes Based on the optimal cutoff value (36.07), the 71 children were divided into a low HALP group (< 36.07, n = 26) and a high HALP group (≥ 36.07, n = 45). The proportions of children requiring mechanical ventilation, PICU admission, and vasoactive drug use were all significantly higher in the low HALP group compared to the high HALP group ( P < 0.05 or P 0.05). See Table 4 . Table 4 Comparisons of clinical outcomes among children with different HALP score groups [n(%)] Clinical Outcomes HALP < 36.07 (n = 26) HALP ≥ 36.07 (n = 45) χ ² P Mechanical Ventilation 8 (30.77) 3 (6.67) - 0.014* PICU Admission 18 (69.23) 7 (15.56) 20.811 < 0.001 Vasoactive Drug Use 16 (61.54) 7 (15.56) 15.910 < 0.001 In-Hospital Death 2 (7.69) 3 (6.67) - 1.000* Note PICU: pediatric intensive care unit; *: Fisher's exact test was used. 2.5 Multivariate Logistic Regression Analysis of Fulminant Myocarditis Using the diagnosis of FM as the dependent variable, variables with P < 0.1 in the univariate analysis were included in the multivariate logistic regression model. The results showed that after adjusting for other factors, elevated high-sensitivity troponin I, reduced left ventricular ejection fraction, and reduced HALP score were independent risk factors for FM (all P < 0.05). For every one-unit decrease in the HALP score, the risk of FM increased by approximately 6.8% ( OR = 0.936). See Table 5 . Table 5 Univariate and multivariate logistic regression analysis of fulminant myocarditis Variables Univariate Analysis OR (95% CI ) P Multivariate Analysis OR (95% CI ) P LVEF (%) -0.013 (-0.019, -0.007) < 0.001 0.911 (0.856, 0.970) 0.003 hs-cTnI (µg/L) 0.004 (0.002, 0.007) 0.003 1.106 (1.017, 1.140) 0.011 HALP Score -0.004 (-0.007, 0) 0.034 0.936 (0.885, 0.991) 0.023 CK-MB (U/L) 0.001 (0,0.002) 0.181 Note LVEF: Left Ventricular Ejection Fraction; hs-cTnI: High-Sensitivity Troponin I; HALP Score: hemoglobin, albumin, lymphocyte, and platelet score; CK-MB: creatine kinase-MB. Discussion This study systematically evaluated the clinical utility of the HALP score in pediatric FM. The principal findings are: (1) the HALP score was significantly lower in children with FM than in those with NFM; (2) the HALP score demonstrated diagnostic value for FM (AUC = 0.724) and emerged as an independent predictor of FM, distinct from conventional markers such as hs-cTnI and LVEF; (3) a low HALP score (< 36.07) was associated with a more severe disease course, predicting significantly higher risks of mechanical ventilation, PICU admission, and vasoactive drug use. The HALP score integrates four readily available laboratory parameters—Hb, Alb, Lym, and Plt [ 11 ]—to provide a composite measure that reflects both systemic inflammation and nutritional status [ 12 , 13 ]. This pathophysiological rationale aligns well with the nature of FM, which is not merely a focal myocardial injury but a systemic illness characterized by an inflammatory storm and immune over-activation [ 14 , 15 ]. Each component of the HALP score can be linked to the pathophysiology of FM: First, hypoalbuminemia is closely tied to acute inflammation and capillary leakage. Pro-inflammatory cytokines (e.g., TNF-α, IL-6, IL-1β) suppress hepatic albumin synthesis and increase vascular permeability, leading to albumin loss [ 16 ]. In models of myocarditis and systemic inflammation, elevated levels of these cytokines correlate with reduced albumin [ 3 , 17 ]. In our cohort, albumin levels were significantly lower in the FM group, indicating a more intense systemic inflammatory state. Second, lymphopenia in critical illness results from multiple mechanisms, including apoptosis, redistribution, and bone-marrow suppression. Inflammatory mediators promote lymphocyte apoptosis [ 18 ] and recruit lymphocytes to sites of inflammation, lowering peripheral counts [ 19 ]; viral infections may also impair lymphocyte function via immune activation [ 20 ]. Although the lymphocyte count in our FM group showed only a trend toward reduction, its contribution to the HALP score supports the notion of an immunosuppressed state. Third, anemia in critically ill patients often reflects inflammation-driven disturbances in iron metabolism: pro-inflammatory cytokines stimulate hepcidin production, which blocks iron release and leads to functional iron deficiency [ 21 ]; concurrently, cytokines can directly suppress erythropoietin synthesis and activity [ 22 ]. The downward trend in hemoglobin observed in the FM group further underscores the presence of systemic inflammation and nutritional compromise. Fourth, thrombocytopenia is common in FM and may result from platelet activation and consumption [ 23 ]. Within the inflammatory milieu, interplay among platelets, endothelium, and the complement system can promote microthrombosis and vascular injury [ 24 , 25 ]. Previous studies have linked a lower HALP score in children with FM to thrombocytopenia and heightened systemic inflammation [ 26 ]. In our data, platelet counts were slightly (though not significantly) lower in the FM group, possibly reflecting consumption during the inflammatory response. Collectively, a reduced HALP score captures the multifaceted pathophysiology of FM—marked by heightened inflammatory consumption, immune dysregulation, nutritional depletion, and potential coagulation activation—aspects that are not fully captured by traditional myocardial-specific biomarkers. Regarding diagnostic performance, established markers such as hs-cTnI and LVEF remain central to FM diagnosis. hs-cTnI directly indicates cardiomyocyte necrosis, while LVEF assesses cardiac pump function. Although the AUC of the HALP score and LVEF did not differ significantly, LVEF reflects a single dimension (cardiac function), whereas the HALP score integrates information on inflammation, nutrition, immunity, and coagulation, offering a theoretically more holistic assessment. Multivariate analysis confirmed that the HALP score retained independent predictive value even after adjustment for strong predictors like hs-cTnI and LVEF, underscoring its unique role as a comprehensive evaluation tool. For prognostic stratification, using the cut-off of 36.07, children in the low-HALP group had significantly higher rates of PICU admission, mechanical ventilation, and vasoactive drug therapy. This indicates that the HALP score not only aids diagnosis but can also identify patients at high risk for intensive care needs. The underlying mechanism likely relates to the systemic inflammation-immunity-nutrition imbalance signified by a low HALP score, which diminishes the child’s tolerance to the hemodynamic stress of myocardial injury and predisposes to multiorgan dysfunction, thereby escalating the demand for respiratory and circulatory support [ 26 – 28 ]. Hence, for children with myocarditis who present with a low HALP score on admission—even if initial cardiac function appears preserved—clinicians should maintain a higher index of suspicion and consider early escalation to intensive monitoring and care. Our findings are consistent with reports of the HALP score in other conditions. For instance, in adults with heart failure, acute myocardial infarction, and sepsis, a low HALP score has been independently associated with adverse outcomes [ 7 , 8 , 28 ], supporting its potential as a cross-disease indicator of critical illness. However, pediatric physiology and disease patterns differ from those of adults. This study is the first to establish a cut-off value of 36.07 for HALP in pediatric FM, offering a concrete reference for clinical use in children. Several limitations should be acknowledged. First, as a single-center retrospective analysis, selection bias may exist. The sample size is modest, and the number of FM cases is relatively small, which could limit statistical power and the robustness of subgroup comparisons. Second, we only used the baseline HALP score at admission; dynamic changes in the score and their relationship with treatment response and long-term outcomes were not examined. Future multi-center, prospective studies with larger cohorts are needed to validate these findings and to explore the utility of serial HALP monitoring. Third, we did not compare the HALP score with newer inflammatory or immune markers such as cytokine profiles or regulatory T-cell counts. Investigating the correlation between the HALP score and such markers, as well as its potential to guide targeted immunomodulatory therapy, merits further research. In conclusion, the HALP score—a simple, cost-effective composite index derived from routine laboratory tests—demonstrates considerable clinical value for early identification, severity assessment, and risk stratification in pediatric FM. It complements traditional myocardial-injury and cardiac-function indicators by reflecting the systemic inflammation-nutrition-immunity status. We propose that the HALP score be incorporated into the initial rapid evaluation of children with suspected myocarditis. For those with low scores, heightened monitoring and early intervention should be considered, which may ultimately improve patient outcomes. Declarations Acknowledgements The authors gratefully thank the parent and child who have been generous with their time for participating in our research. Author contributions Z.D.-f. and Z.J. conceived the study and designed the methodology; Z.J. performed data collection; Z.J. and L.Q.-s. conducted data analysis; L.Q.-s. wrote the first draft. All authors reviewed and approved the final manuscript. Funding This research was supported Clinical Medical Center Project of Hainan Province, China, No. QWYH202175. Data availability No datasets were generated or analyzed during the current study. Data availability statements The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was approved by the Ethics Committee of Affiliated Hainan Women and Children's Medical Center of Hainan Medical University (HNWCMC 2025-14). Informed consent form had been signed by parent of the child. This study adhered to the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details Pediatrics Department, Affiliated Hainan Women and Children's Medical Center of Hainan Medical University, Haikou, Hainan, China. References Cui G, Nie J, Li H, Wang L, Miao K, Zhao C et al. The clinicopathologic features of fulminant myocarditis. J Adv Res. 2025:S2090-1232(25)00449-7. Kanaoka K, Onoue K, Terasaki S, Nakai M, Iwanaga Y, Miyamoto Y, et al. Changes in Cardiac Function Following Fulminant Myocarditis. Circ Heart Fail. 2024;17(4):e010840. Chinese Society of Cardiology, Chinese Medical Association, Jiang WG, Shu J, Wang H, Hui DW, Li R. Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis. Sci China Life Sci. 2024;67(5):913–39. Li J, Zheng J, Wang P, Lv D. Prognostic significance of hemoglobin, albumin, lymphocyte and platelet score in solid tumors: a pooled study. Front Immunol. 2024;15:1483855. Gao W, Yu L, Zhang Y, Jin S, Chen Z, Chen X, et al. Objective nutritional indices as an independent predictor of functional outcome after endovascular therapy for acute ischemic stroke: a cohort study in a Chinese population. Front Nutr. 2025;12:1504208. Davidson BP, Hodovan J, Layoun ME, Golwala H, Zahr F, Lindner JR. Echocardiographic Ischemic Memory Molecular Imaging for Point-of-Care Detection of Myocardial Ischemia. J Am Coll Cardiol. 2021;78(20):1990–2000. Swain L, Bhave S, Qiao X, Reyelt L, Everett KD, Awata J, et al. Novel Role for Cardiolipin as a Target of Therapy to Mitigate Myocardial Injury Caused by Venoarterial Extracorporeal Membrane Oxygenation. Circulation. 2024;149(17):1341–53. Law YM, Lal AK, Chen S, Čiháková D, Cooper LT Jr, Deshpande S, et al. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation. 2021;144(6):e123–35. Kociol RD, Cooper LT, Fang JC, Moslehi JJ, Pang PS, Sabe MA, et al. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association. Circulation. 2020;141(6):e69–92. Xu H, Zheng X, Ai J, Yang L. Hemoglobin, albumin, lymphocyte, and platelet (HALP) score and cancer prognosis: A systematic review and meta-analysis of 13,110 patients. Int Immunopharmacol. 2023;114:109496. Jiang T, Sun H, Xue S, Xu T, Xia W, Wang Y, et al. Prognostic significance of hemoglobin, albumin, lymphocyte, and platelet (HALP) score in breast cancer: a propensity score-matching study. Cancer Cell Int. 2024;24(1):230. Liu S, Huang J, Hu X, Chen S, Lin M. The association of HALP score with low muscle mass in older adults. Front Nutr. 2025;12:1618736. He W, Zhou L, Xu K, Li H, Wang JJ, Chen C, et al. Immunopathogenesis and immunomodulatory therapy for myocarditis. Sci China Life Sci. 2023;66(9):2112–37. Nie J, Zhou L, Tian W, Liu X, Yang L, Yang X, et al. Deep insight into cytokine storm: from pathogenesis to treatment. Signal Transduct Target Ther. 2025;10(1):112. Liu B, Yang X, Chang H, Li P, Chang H, Wang X, et al. Hepatic soluble epoxide hydrolase mediates osteoclastogenesis by suppressing the Nrf2 signaling pathway: a novel mechanism of redox imbalance in osteoporosis. Free Radic Biol Med. 2026;243:466–80. He W, Wu J, Wang D, Chen W, Yan Y, He Q et al. Plasma proteomics identifies S100A8/A9 as a novel biomarker and therapeutic target for fulminant myocarditis. J Adv Res. 2025:S2090-1232(25)00391-1. Wang Z, Zhang W, Chen L, Lu X, Tu Y. Lymphopenia in sepsis: a narrative review. Crit Care. 2024;28(1):315. Rosichini M, Bordoni V, Silvestris DA, Mariotti D, Matusali G, Cardinale A, et al. SARS-CoV-2 infection of thymus induces loss of function that correlates with disease severity. J Allergy Clin Immunol. 2023;151(4):911–21. Baliu-Piqué M, Tesselaar K, Borghans JAM. Are homeostatic mechanisms aiding the reconstitution of the T-cell pool during lymphopenia in humans? Front Immunol. 2022;13:1059481. Marques O, Horvat NK, Zechner L, Colucci S, Sparla R, Zimmermann S, et al. Inflammation-driven NF-κB signaling represses ferroportin transcription in macrophages via HDAC1 and HDAC3. Blood. 2025;145(8):866–80. Corwin HL, Napolitano LM. Anemia of Critical Illness: A Concise Definitive Review in Critical Care. Crit Care Med. 2026;54(2):343–53. Esefeld M, Handtke S, Kaiser R, Nicolai L, Di Fina L, Rossaro D, et al. Platelet-activating histone/antihistone IgG complexes in anti-PF4-negative thrombosis and thrombocytopenia syndrome. Blood Adv. 2025;9(16):4323–35. Lim MS, Mcrae S. COVID-19 and immunothrombosis: Pathophysiology and therapeutic implications. Crit Rev Oncol Hematol. 2021;168:103529. Meyers S, Crescente M, Verhamme P, Martinod K. Staphylococcus aureus and Neutrophil Extracellular Traps: The Master Manipulator Meets Its Match in Immunothrombosis. Arterioscler Thromb Vasc Biol. 2022;42(3):261–76. Aladag P, Avci A. The brand-new predictor index of fulminant process in patients with acute myocarditis: hemoglobin, albumin, lymphocyte and platelet (HALP) score. Front Nutr. 2025;12:1674368. Li H, Zhang M, Zhao Q, Zhao W, Zhuang Y, Wang J, et al. Self-recruited neutrophils trigger over-activated innate immune response and phenotypic change of cardiomyocytes in fulminant viral myocarditis. Cell Discov. 2023;9(1):103. Ueda T, Amiya E, Hatano M, Inoue K, Ishida J, Minatsuki S, et al. Prognostic Factors Associated With Early Recovery From Veno-Arterial Extracorporeal Membrane Oxygenation Support in Patients With Fulminant Myocarditis. J Am Heart Assoc. 2025;14(12):e039673. Nam H, Cha JH, Choi KH, Chung CR, Yang JH, Suh GY, et al. Association Between Initial Left Ventricular Systolic Dysfunction and Clinical Outcome in Sepsis: A Multicenter Cohort Study. Crit Care Med. 2025;53(9):e1759–69. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8832543","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595906153,"identity":"9b70f0e4-95c7-4361-86d5-a026614ef784","order_by":0,"name":"Qishuai Liang","email":"","orcid":"","institution":"Affiliated Hainan Women and Children's Medical Center of Hainan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qishuai","middleName":"","lastName":"Liang","suffix":""},{"id":595906154,"identity":"d290c648-7be2-4240-8337-b8c66e326bf3","order_by":1,"name":"Tingting Feng","email":"","orcid":"","institution":"Affiliated Hainan Women and Children's Medical Center of Hainan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Feng","suffix":""},{"id":595906159,"identity":"1f747407-792a-4312-a77d-254924051975","order_by":2,"name":"Jun Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIie2RsWrDMBCGTwjiRY1WCUrfoHBQcFsw7atIFWgKdM0oMGTqkDF9i06dZTy4g2lWQxaHQmZn61BKnZQMHSJn7KBvueU+fv47gEjkP0KTqlPT7IInTrcwzRjnbkBJmIW2tlfyyX8g1PZcLvyAwiEl61mpXxq9EWRWZuhU2LjMwbaqT8HGWAGjJUPwpNtOjitpSSrcdZH1xtwAW7Fr6qh8fg0poMQuZVxNdANixW6dH9GzsIJC912cf+wE4DtDrwaVdK/M39SDAOVPUZhB9Xtk0zc3TC6KPNxlWRXrz8MryffdPed50W0Dyh/o134Qd+J+JBKJRI7xA6JEW57X+kTSAAAAAElFTkSuQmCC","orcid":"","institution":"Affiliated Hainan Women and Children's Medical Center of Hainan Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"","lastName":"Zheng","suffix":""},{"id":595906164,"identity":"49f67b07-c257-44b1-907b-1f64faf2e77c","order_by":3,"name":"Dufei Zhang","email":"","orcid":"","institution":"Affiliated Hainan Women and Children's Medical Center of Hainan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dufei","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-02-09 16:15:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8832543/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8832543/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-026-06820-8","type":"published","date":"2026-04-02T15:59:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":103507103,"identity":"bb23b1d9-c0de-4297-b6bb-2684ce477c7b","added_by":"auto","created_at":"2026-02-26 13:40:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101660,"visible":true,"origin":"","legend":"\u003cp\u003e(A) ROC curves assessing the predictive value of the HALP score and left ventricular ejection fraction for fulminant myocarditis;(B) ROC curve assessing the predictive value of high-sensitivity troponin I for fulminant myocarditis.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8832543/v1/c8cfa0f499329a719c53b37d.jpeg"},{"id":106344747,"identity":"db32d35c-d522-47bc-9200-5180878ebbb0","added_by":"auto","created_at":"2026-04-07 16:16:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1036376,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8832543/v1/e3da266e-023a-405f-811c-df8fe26b6948.pdf"},{"id":103437890,"identity":"c48998ee-c092-4b42-8bcc-271a7e003811","added_by":"auto","created_at":"2026-02-25 16:52:29","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22833,"visible":true,"origin":"","legend":"","description":"","filename":"RAWDATA.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8832543/v1/79227ec0afe6184d27fbbc60.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Novel Evaluation Indicator for Pediatric Fulminant Myocarditis: Diagnostic and Prognostic Value of the HALP Score","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFulminant myocarditis (FM) represents one of the most critical and life-threatening conditions in pediatric cardiology. It is marked by abrupt onset and rapid progression, often leading to severe heart failure, malignant arrhythmias, cardiogenic shock, or sudden death, with a notably high mortality rate [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Early and accurate identification of FM, along with timely assessment of its severity, is essential for initiating effective life-support measures and improving clinical outcomes. Current diagnostic approaches largely depend on clinical manifestations, electrocardiographic changes, elevated myocardial injury biomarkers, and echocardiographic evidence of cardiac dysfunction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, these conventional indicators offer limited insight into the systemic inflammatory response, immune dysregulation, and multi-organ involvement characteristic of the disease. Emerging evidence highlights the central role of systemic inflammation and immune imbalance in the pathogenesis and progression of FM [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Consequently, identifying biomarkers that comprehensively reflect the body's inflammatory, nutritional, and immune status has become a key focus in refining risk stratification strategies for FM.\u003c/p\u003e \u003cp\u003eThe HALP score\u0026mdash;a novel composite index derived from Hb, Alb, lymphocyte count (Lym), and platelet count (Plt)---provides an integrated perspective on a patient's systemic inflammation-nutrition-immunity profile [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This score has demonstrated prognostic utility across various clinical settings, including solid tumors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], sepsis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and adult cardiovascular diseases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Nevertheless, its application in pediatric fulminant myocarditis remains largely unexplored.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to systematically evaluate the diagnostic and prognostic value of the HALP score in pediatric FM through a retrospective analysis of clinical data from children with myocarditis treated at our institution over the past decade. The objective is to establish a simple, practical tool to aid in the early identification of high-risk patients and to support optimized therapeutic decision-making in clinical practice.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Study Population\u003c/h2\u003e \u003cp\u003eThis single-center retrospective study consecutively included 71 pediatric patients diagnosed with myocarditis and admitted to our center between January 1, 2013, and December 31, 2025, through the hospital electronic medical record system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Diagnostic Criteria\u003c/h2\u003e \u003cp\u003eMyocarditis diagnosis was based on the 2020 American Heart Association scientific statement, \"Recognition and Initial Management of Fulminant Myocarditis\" [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], incorporating clinical manifestations, elevated myocardial injury markers, electrocardiographic abnormalities, echocardiographic evidence of cardiac structural and/or functional impairment, and exclusion of other definitive etiologies.\u003c/p\u003e \u003cp\u003eFulminant myocarditis (FM) was diagnosed according to established consensus criteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], requiring: (1) acute onset; (2) rapid clinical deterioration, typically progressing to severe heart failure, cardiogenic shock, or malignant arrhythmias within two weeks of symptom onset; and (3) need for advanced life support, including inotropic therapy, mechanical ventilation, or mechanical circulatory support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Grouping\u003c/h2\u003e \u003cp\u003ePatients were stratified into a fulminant myocarditis group (FM group) and a non-fulminant myocarditis group (NFM group) based on the above criteria.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Exclusion Criteria\u003c/h2\u003e \u003cp\u003eExclusion criteria comprised: (1) congenital heart disease; (2) known chronic cardiac conditions; (3) autoimmune diseases, malignancies, or severe hepatic or renal dysfunction; (4) severe anemia; (5) severe malnutrition; (6) hemorrhagic disorders; and (7) significantly incomplete clinical data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Data Collection\u003c/h2\u003e \u003cp\u003eTwo trained researchers independently extracted and cross-verified the following information from the electronic medical records:\u003c/p\u003e \u003cp\u003e(1) General information: age and sex.\u003c/p\u003e \u003cp\u003e(2) Clinical symptoms and signs at admission: precordial discomfort, fever, Adams-Stokes attacks, altered consciousness, dyspnea, nausea/vomiting, muffled heart sounds, arrhythmia, etc.\u003c/p\u003e \u003cp\u003e(3) Laboratory parameters: results from the first venous blood test within 24 hours of admission, including white blood cell (WBC) count, C-reactive protein (CRP), high-sensitivity troponin I (hs-cTnI), creatine kinase-MB (CK-MB), Alb, Hb, absolute lymphocyte count, and Plt.\u003c/p\u003e \u003cp\u003e(4) Imaging and electrocardiographic findings: results of the initial post-admission echocardiogram (left ventricular ejection fraction [LVEF], interventricular septal/ventricular wall motion, pericardial effusion, left ventricular enlargement) and electrocardiogram (ST-T segment changes, arrhythmias, etc.).\u003c/p\u003e \u003cp\u003e(5) Treatment and clinical outcomes: admission to the Pediatric Intensive Care Unit (PICU), use of mechanical ventilation, administration of vasoactive drugs, and in-hospital mortality. Prognosis was defined as either death during hospitalization or survival to discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.6 HALP Score Calculation\u003c/h2\u003e \u003cp\u003eThe HALP score was calculated using the formula[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]: HALP\u0026thinsp;=\u0026thinsp;Hb (g/L) \u0026times; Alb (g/L) \u0026times; Lym (\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L) / Plt (\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L). All component values were obtained from the first laboratory test performed at admission.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e1.7 Statistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using SPSS software, version 26.0. Continuous variables following a normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared between groups using the independent samples \u003cem\u003et\u003c/em\u003e-test. Continuous variables not conforming to a normal distribution were reported as median (interquartile range) and compared using the Mann\u0026ndash;Whitney U test. Categorical variables were described as numbers (percentages) and compared using the chi-square test or Fisher's exact test, as appropriate. Receiver operating characteristic (ROC) curves were constructed to evaluate the diagnostic performance of different indicators for fulminant myocarditis. Based on the optimal cut-off value of the HALP score, patients were stratified into low-HALP and high-HALP groups, and differences in clinical outcomes between the two groups were compared. Variables showing a \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analysis were included in a multivariate logistic regression model to identify independent predictors of fulminant myocarditis. All statistical tests were two-sided, with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Comparison of Baseline Characteristics and Clinical Features between Groups\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were observed in age, sex distribution, or clinical manifestations between the FM group and the NFM group (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Baseline Characteristics and Clinical Manifestations between the Fulminant Myocarditis Group and the Non-Fulminant Myocarditis Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Fulminant Group (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFulminant Group (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e/\u003cem\u003eχ\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [years, M (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.10 (4.75, 11.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.25 (5.03, 9.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (67.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (45.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrecordial Discomfort [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (57.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (40.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.612\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (42.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (50.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.575\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea/Vomiting [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (28.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (40.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal Pain [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (16.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (27.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdams-Stokes Attack [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (18.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.070*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmia [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (22.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (40.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote:\u0026nbsp;*Fisher's exact test was used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Comparison of Laboratory and Imaging Indicators between Groups\u003c/h2\u003e \u003cp\u003eCompared to the NFM group, patients in the FM group exhibited more pronounced inflammatory activation and myocardial injury. Levels of hs-cTnI and CK-MB were significantly elevated in the FM group (both \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas Alb levels and the HALP score were markedly lower (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). No statistically significant differences were observed between the two groups in Lym count, Plt count, Hb, or CRP levels (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The LVEF was significantly reduced in the FM group, and the proportion of patients with diminished interventricular septum/ventricular wall motion was significantly higher compared to the NFM group (both \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Detailed results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Laboratory and Imaging Indicators between the Fulminant Myocarditis Group and the Non-Fulminant Myocarditis Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Fulminant Group (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFulminant Group (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e/\u003cem\u003eχ\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC Count (\u0026times;10⁹/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.17 (6.43, 11.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.65(7.78, 15.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.77(0.69, 14.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.81(1.24, 47.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehs-cTnI (\u0026micro;g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.02 (0.01, 1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.10 (2.50, 50.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCK-MB (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.00 (19.50, 45.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.50 (40.50, 120.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.00(34.00, 57.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.00(38.75, 58.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlb (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.20 (40.00, 46.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.55 (38.88, 42.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHALP Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.22 (37.08, 65.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.06 (24.95, 49.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129(118, 135.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125.5(108.5, 133.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLym Count (\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.51 (1.71, 3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.73 (1.41, 2.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlt Count (\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e270.00 (241.50, 356.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e249.50 (181.50, 316.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.00 (63.00, 69.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.50 (32.50, 56.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiminished Interventricular Septum / Ventricular Wall Motion [n(%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (10.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (40.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericardial Effusion [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (8.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (27.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.060*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft Ventricular Enlargement [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (12.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (22.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e\u0026nbsp;WBC: White Blood Cell; CRP: C-Reactive Protein; hs-cTnI: High-Sensitivity Troponin I; CK-MB: Creatine Kinase-MB; Alb: Albumin; HALP Score:hemoglobin, albumin, lymphocyte, and platelet score; Hb:Hemoglobin; CK-MB: creatine kinase-MB; Lym: Lymphocyte; Plt: Platelet; LVEF: Left Ventricular Ejection Fraction; *Fisher's exact test was used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Diagnostic Value of the HALP Score and Other Indicators for Fulminant Myocarditis\u003c/h2\u003e \u003cp\u003eROC curve analysis showed that high-sensitivity troponin I had the highest diagnostic efficacy for FM (AUC\u0026thinsp;=\u0026thinsp;0.865), followed by left ventricular ejection fraction (AUC\u0026thinsp;=\u0026thinsp;0.831). The AUC of the HALP score was 0.724 (95% \u003cem\u003eCI\u003c/em\u003e: 0.593\u0026ndash;0.856), with an optimal cutoff value of 36.07, yielding a sensitivity of 77.6% and specificity of 68.2%. See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The DeLong test showed no statistically significant difference between the AUC of the HALP score and LVEF (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.308).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of ROC Curve Analysis for Diagnosing Fulminant Myocarditis Using Various Indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% \u003cem\u003eCI\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Cut-off Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYouden Index\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehs-cTnI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.865 (0.770\u0026ndash;0.959)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 \u0026micro;g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e93.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.831 (0.708\u0026ndash;0.956)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e87.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHALP Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.724 (0.593\u0026ndash;0.856)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e77.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote\u003c/b\u003e AUC: area under the ROC curve; hs-cTnI: High-Sensitivity Troponin I; LVEF: Left Ventricular Ejection Fraction; HALP Score: hemoglobin, albumin, lymphocyte, and platelet score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA B\u003c/p\u003e \u003cp\u003eFigure 1 (A) ROC curves assessing the predictive value of the HALP score and left ventricular ejection fraction for fulminant myocarditis;(B) ROC curve assessing the predictive value of high-sensitivity troponin I for fulminant myocarditis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Association of HALP Score with Clinical Outcomes\u003c/h2\u003e \u003cp\u003eBased on the optimal cutoff value (36.07), the 71 children were divided into a low HALP group (\u0026lt;\u0026thinsp;36.07, n\u0026thinsp;=\u0026thinsp;26) and a high HALP group (\u0026ge;\u0026thinsp;36.07, n\u0026thinsp;=\u0026thinsp;45). The proportions of children requiring mechanical ventilation, PICU admission, and vasoactive drug use were all significantly higher in the low HALP group compared to the high HALP group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 or \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There was no statistically significant difference in in-hospital mortality between the two groups (7.69% vs. 6.67%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of clinical outcomes among children with different HALP score groups [n(%)]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHALP\u0026thinsp;\u0026lt;\u0026thinsp;36.07 (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHALP\u0026thinsp;\u0026ge;\u0026thinsp;36.07 (n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical Ventilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (30.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePICU Admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (69.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (15.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVasoactive Drug Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (61.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (15.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-Hospital Death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e PICU: pediatric intensive care unit; *: Fisher's exact test was used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Multivariate Logistic Regression Analysis of Fulminant Myocarditis\u003c/h2\u003e \u003cp\u003eUsing the diagnosis of FM as the dependent variable, variables with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in the univariate analysis were included in the multivariate logistic regression model. The results showed that after adjusting for other factors, elevated high-sensitivity troponin I, reduced left ventricular ejection fraction, and reduced HALP score were independent risk factors for FM (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For every one-unit decrease in the HALP score, the risk of FM increased by approximately 6.8% (\u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.936). See Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate logistic regression analysis of fulminant myocarditis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariate Analysis\u003c/p\u003e \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e (95% \u003cem\u003eCI\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultivariate Analysis \u003cem\u003eOR\u003c/em\u003e (95% \u003cem\u003eCI\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.013 (-0.019, -0.007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.911 (0.856, 0.970)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehs-cTnI (\u0026micro;g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.004 (0.002, 0.007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.106 (1.017, 1.140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHALP Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.004 (-0.007, 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.936 (0.885, 0.991)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCK-MB (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.001 (0,0.002)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e LVEF: Left Ventricular Ejection Fraction; hs-cTnI: High-Sensitivity Troponin I; HALP Score: hemoglobin, albumin, lymphocyte, and platelet score; CK-MB: creatine kinase-MB.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study systematically evaluated the clinical utility of the HALP score in pediatric FM. The principal findings are: (1) the HALP score was significantly lower in children with FM than in those with NFM; (2) the HALP score demonstrated diagnostic value for FM (AUC\u0026thinsp;=\u0026thinsp;0.724) and emerged as an independent predictor of FM, distinct from conventional markers such as hs-cTnI and LVEF; (3) a low HALP score (\u0026lt;\u0026thinsp;36.07) was associated with a more severe disease course, predicting significantly higher risks of mechanical ventilation, PICU admission, and vasoactive drug use.\u003c/p\u003e \u003cp\u003eThe HALP score integrates four readily available laboratory parameters\u0026mdash;Hb, Alb, Lym, and Plt [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;to provide a composite measure that reflects both systemic inflammation and nutritional status [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This pathophysiological rationale aligns well with the nature of FM, which is not merely a focal myocardial injury but a systemic illness characterized by an inflammatory storm and immune over-activation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Each component of the HALP score can be linked to the pathophysiology of FM: First, hypoalbuminemia is closely tied to acute inflammation and capillary leakage. Pro-inflammatory cytokines (e.g., TNF-α, IL-6, IL-1β) suppress hepatic albumin synthesis and increase vascular permeability, leading to albumin loss [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In models of myocarditis and systemic inflammation, elevated levels of these cytokines correlate with reduced albumin [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our cohort, albumin levels were significantly lower in the FM group, indicating a more intense systemic inflammatory state. Second, lymphopenia in critical illness results from multiple mechanisms, including apoptosis, redistribution, and bone-marrow suppression. Inflammatory mediators promote lymphocyte apoptosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and recruit lymphocytes to sites of inflammation, lowering peripheral counts [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; viral infections may also impair lymphocyte function via immune activation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Although the lymphocyte count in our FM group showed only a trend toward reduction, its contribution to the HALP score supports the notion of an immunosuppressed state. Third, anemia in critically ill patients often reflects inflammation-driven disturbances in iron metabolism: pro-inflammatory cytokines stimulate hepcidin production, which blocks iron release and leads to functional iron deficiency [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; concurrently, cytokines can directly suppress erythropoietin synthesis and activity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The downward trend in hemoglobin observed in the FM group further underscores the presence of systemic inflammation and nutritional compromise. Fourth, thrombocytopenia is common in FM and may result from platelet activation and consumption [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Within the inflammatory milieu, interplay among platelets, endothelium, and the complement system can promote microthrombosis and vascular injury [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Previous studies have linked a lower HALP score in children with FM to thrombocytopenia and heightened systemic inflammation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In our data, platelet counts were slightly (though not significantly) lower in the FM group, possibly reflecting consumption during the inflammatory response. Collectively, a reduced HALP score captures the multifaceted pathophysiology of FM\u0026mdash;marked by heightened inflammatory consumption, immune dysregulation, nutritional depletion, and potential coagulation activation\u0026mdash;aspects that are not fully captured by traditional myocardial-specific biomarkers.\u003c/p\u003e \u003cp\u003eRegarding diagnostic performance, established markers such as hs-cTnI and LVEF remain central to FM diagnosis. hs-cTnI directly indicates cardiomyocyte necrosis, while LVEF assesses cardiac pump function. Although the AUC of the HALP score and LVEF did not differ significantly, LVEF reflects a single dimension (cardiac function), whereas the HALP score integrates information on inflammation, nutrition, immunity, and coagulation, offering a theoretically more holistic assessment. Multivariate analysis confirmed that the HALP score retained independent predictive value even after adjustment for strong predictors like hs-cTnI and LVEF, underscoring its unique role as a comprehensive evaluation tool.\u003c/p\u003e \u003cp\u003eFor prognostic stratification, using the cut-off of 36.07, children in the low-HALP group had significantly higher rates of PICU admission, mechanical ventilation, and vasoactive drug therapy. This indicates that the HALP score not only aids diagnosis but can also identify patients at high risk for intensive care needs. The underlying mechanism likely relates to the systemic inflammation-immunity-nutrition imbalance signified by a low HALP score, which diminishes the child\u0026rsquo;s tolerance to the hemodynamic stress of myocardial injury and predisposes to multiorgan dysfunction, thereby escalating the demand for respiratory and circulatory support [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Hence, for children with myocarditis who present with a low HALP score on admission\u0026mdash;even if initial cardiac function appears preserved\u0026mdash;clinicians should maintain a higher index of suspicion and consider early escalation to intensive monitoring and care.\u003c/p\u003e \u003cp\u003eOur findings are consistent with reports of the HALP score in other conditions. For instance, in adults with heart failure, acute myocardial infarction, and sepsis, a low HALP score has been independently associated with adverse outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], supporting its potential as a cross-disease indicator of critical illness. However, pediatric physiology and disease patterns differ from those of adults. This study is the first to establish a cut-off value of 36.07 for HALP in pediatric FM, offering a concrete reference for clinical use in children.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, as a single-center retrospective analysis, selection bias may exist. The sample size is modest, and the number of FM cases is relatively small, which could limit statistical power and the robustness of subgroup comparisons. Second, we only used the baseline HALP score at admission; dynamic changes in the score and their relationship with treatment response and long-term outcomes were not examined. Future multi-center, prospective studies with larger cohorts are needed to validate these findings and to explore the utility of serial HALP monitoring. Third, we did not compare the HALP score with newer inflammatory or immune markers such as cytokine profiles or regulatory T-cell counts. Investigating the correlation between the HALP score and such markers, as well as its potential to guide targeted immunomodulatory therapy, merits further research.\u003c/p\u003e \u003cp\u003eIn conclusion, the HALP score\u0026mdash;a simple, cost-effective composite index derived from routine laboratory tests\u0026mdash;demonstrates considerable clinical value for early identification, severity assessment, and risk stratification in pediatric FM. It complements traditional myocardial-injury and cardiac-function indicators by reflecting the systemic inflammation-nutrition-immunity status. We propose that the HALP score be incorporated into the initial rapid evaluation of children with suspected myocarditis. For those with low scores, heightened monitoring and early intervention should be considered, which may ultimately improve patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e The authors gratefully thank the parent and child who have been generous with their time for participating in our research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e Z.D.-f. and Z.J. conceived the study and designed the methodology; Z.J. performed data collection; Z.J. and L.Q.-s. conducted data analysis; L.Q.-s. wrote the first draft. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e This research was supported Clinical Medical Center Project of Hainan Province, China, No. QWYH202175.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e No datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e This study was approved by the Ethics Committee of Affiliated Hainan Women and Children\u0026apos;s Medical Center of Hainan Medical University (HNWCMC 2025-14). Informed consent form had been signed by parent of the child. This study adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatrics Department, Affiliated Hainan Women and Children\u0026apos;s Medical Center of Hainan Medical University, Haikou, Hainan, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCui G, Nie J, Li H, Wang L, Miao K, Zhao C et al. The clinicopathologic features of fulminant myocarditis. J Adv Res. 2025:S2090-1232(25)00449-7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanaoka K, Onoue K, Terasaki S, Nakai M, Iwanaga Y, Miyamoto Y, et al. Changes in Cardiac Function Following Fulminant Myocarditis. Circ Heart Fail. 2024;17(4):e010840.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChinese Society of Cardiology, Chinese Medical Association, Jiang WG, Shu J, Wang H, Hui DW, Li R. Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis. Sci China Life Sci. 2024;67(5):913\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi J, Zheng J, Wang P, Lv D. Prognostic significance of hemoglobin, albumin, lymphocyte and platelet score in solid tumors: a pooled study. Front Immunol. 2024;15:1483855.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGao W, Yu L, Zhang Y, Jin S, Chen Z, Chen X, et al. Objective nutritional indices as an independent predictor of functional outcome after endovascular therapy for acute ischemic stroke: a cohort study in a Chinese population. Front Nutr. 2025;12:1504208.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavidson BP, Hodovan J, Layoun ME, Golwala H, Zahr F, Lindner JR. Echocardiographic Ischemic Memory Molecular Imaging for Point-of-Care Detection of Myocardial Ischemia. J Am Coll Cardiol. 2021;78(20):1990\u0026ndash;2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwain L, Bhave S, Qiao X, Reyelt L, Everett KD, Awata J, et al. Novel Role for Cardiolipin as a Target of Therapy to Mitigate Myocardial Injury Caused by Venoarterial Extracorporeal Membrane Oxygenation. Circulation. 2024;149(17):1341\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaw YM, Lal AK, Chen S, Čih\u0026aacute;kov\u0026aacute; D, Cooper LT Jr, Deshpande S, et al. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation. 2021;144(6):e123\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKociol RD, Cooper LT, Fang JC, Moslehi JJ, Pang PS, Sabe MA, et al. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association. Circulation. 2020;141(6):e69\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu H, Zheng X, Ai J, Yang L. Hemoglobin, albumin, lymphocyte, and platelet (HALP) score and cancer prognosis: A systematic review and meta-analysis of 13,110 patients. Int Immunopharmacol. 2023;114:109496.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJiang T, Sun H, Xue S, Xu T, Xia W, Wang Y, et al. Prognostic significance of hemoglobin, albumin, lymphocyte, and platelet (HALP) score in breast cancer: a propensity score-matching study. Cancer Cell Int. 2024;24(1):230.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu S, Huang J, Hu X, Chen S, Lin M. The association of HALP score with low muscle mass in older adults. Front Nutr. 2025;12:1618736.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe W, Zhou L, Xu K, Li H, Wang JJ, Chen C, et al. Immunopathogenesis and immunomodulatory therapy for myocarditis. Sci China Life Sci. 2023;66(9):2112\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNie J, Zhou L, Tian W, Liu X, Yang L, Yang X, et al. Deep insight into cytokine storm: from pathogenesis to treatment. Signal Transduct Target Ther. 2025;10(1):112.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu B, Yang X, Chang H, Li P, Chang H, Wang X, et al. Hepatic soluble epoxide hydrolase mediates osteoclastogenesis by suppressing the Nrf2 signaling pathway: a novel mechanism of redox imbalance in osteoporosis. Free Radic Biol Med. 2026;243:466\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe W, Wu J, Wang D, Chen W, Yan Y, He Q et al. Plasma proteomics identifies S100A8/A9 as a novel biomarker and therapeutic target for fulminant myocarditis. J Adv Res. 2025:S2090-1232(25)00391-1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Z, Zhang W, Chen L, Lu X, Tu Y. Lymphopenia in sepsis: a narrative review. Crit Care. 2024;28(1):315.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosichini M, Bordoni V, Silvestris DA, Mariotti D, Matusali G, Cardinale A, et al. SARS-CoV-2 infection of thymus induces loss of function that correlates with disease severity. J Allergy Clin Immunol. 2023;151(4):911\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaliu-Piqu\u0026eacute; M, Tesselaar K, Borghans JAM. Are homeostatic mechanisms aiding the reconstitution of the T-cell pool during lymphopenia in humans? Front Immunol. 2022;13:1059481.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarques O, Horvat NK, Zechner L, Colucci S, Sparla R, Zimmermann S, et al. Inflammation-driven NF-κB signaling represses ferroportin transcription in macrophages via HDAC1 and HDAC3. Blood. 2025;145(8):866\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorwin HL, Napolitano LM. Anemia of Critical Illness: A Concise Definitive Review in Critical Care. Crit Care Med. 2026;54(2):343\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsefeld M, Handtke S, Kaiser R, Nicolai L, Di Fina L, Rossaro D, et al. Platelet-activating histone/antihistone IgG complexes in anti-PF4-negative thrombosis and thrombocytopenia syndrome. Blood Adv. 2025;9(16):4323\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim MS, Mcrae S. COVID-19 and immunothrombosis: Pathophysiology and therapeutic implications. Crit Rev Oncol Hematol. 2021;168:103529.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeyers S, Crescente M, Verhamme P, Martinod K. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and Neutrophil Extracellular Traps: The Master Manipulator Meets Its Match in Immunothrombosis. Arterioscler Thromb Vasc Biol. 2022;42(3):261\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAladag P, Avci A. The brand-new predictor index of fulminant process in patients with acute myocarditis: hemoglobin, albumin, lymphocyte and platelet (HALP) score. Front Nutr. 2025;12:1674368.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi H, Zhang M, Zhao Q, Zhao W, Zhuang Y, Wang J, et al. Self-recruited neutrophils trigger over-activated innate immune response and phenotypic change of cardiomyocytes in fulminant viral myocarditis. Cell Discov. 2023;9(1):103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUeda T, Amiya E, Hatano M, Inoue K, Ishida J, Minatsuki S, et al. Prognostic Factors Associated With Early Recovery From Veno-Arterial Extracorporeal Membrane Oxygenation Support in Patients With Fulminant Myocarditis. J Am Heart Assoc. 2025;14(12):e039673.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNam H, Cha JH, Choi KH, Chung CR, Yang JH, Suh GY, et al. Association Between Initial Left Ventricular Systolic Dysfunction and Clinical Outcome in Sepsis: A Multicenter Cohort Study. Crit Care Med. 2025;53(9):e1759\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Fulminant myocarditis, HALP score, Diagnosis, Prognosis","lastPublishedDoi":"10.21203/rs.3.rs-8832543/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8832543/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Pediatric fulminant myocarditis (FM) is characterized by a critical and rapidly progressive course. Current diagnostic approaches primarily rely on cardiac function and myocardial injury markers, which fail to comprehensively assess the associated systemic inflammation and immune dysregulation. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score, a composite index integrating hemoglobin(Hb), albumin (Alb), lymphocyte count (Lym), and platelet count (Plt), offers a new perspective for evaluating the severity of pediatric fulminant myocarditis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To evaluate the diagnostic and prognostic utility of the HALP score in pediatric patients with fulminant myocarditis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This retrospective study included 71 children with myocarditis (22 with FM, 49 with non-fulminant myocarditis [NFM]). The HALP score was calculated from admission laboratory parameters (Hb × Alb × Lym / Plt). Its diagnostic performance was assessed via receiver operating characteristic (ROC) curve analysis. Associations with clinical outcomes (Pediatric Intensive Care Unit [PICU] admission, mechanical ventilation, vasoactive drug use) were analyzed. Independent predictors of FM were identified using multivariate logistic regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The median HALP score was significantly lower in the FM group compared to the NFM group (27.06 vs. 50.22, \u003cem\u003eP\u003c/em\u003e=0.005). The HALP score had an area under the ROC curve (AUC) of 0.724 for diagnosing FM, with an optimal cutoff of 36.07 (sensitivity 77.6%, specificity 68.2%). Based on this cutoff, children in the low-HALP group (\u0026lt;36.07, n=26) had significantly higher rates of mechanical ventilation (30.77% vs. 6.67%, \u003cem\u003eP\u003c/em\u003e=0.014), PICU admission (69.23% vs. 15.56%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and vasoactive drug use (61.54% vs. 15.56%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) compared to the high-HALP group (≥36.07, n=45). Multivariate analysis confirmed that a lower HALP score (\u003cem\u003eOR\u003c/em\u003e=0.936, 95% \u003cem\u003eCI\u003c/em\u003e: 0.885-0.991, \u003cem\u003eP\u003c/em\u003e=0.023), along with elevated high-sensitivity troponin I (hs-cTnI) (\u003cem\u003eOR\u003c/em\u003e=1.106, 95% \u003cem\u003eCI\u003c/em\u003e: 1.017-1.196, \u003cem\u003eP\u003c/em\u003e=0.011) and reduced left ventricular ejection fraction (LVEF) (\u003cem\u003eOR\u003c/em\u003e=0.911, 95% \u003cem\u003eCI\u003c/em\u003e: 0.856-0.970, \u003cem\u003eP\u003c/em\u003e=0.003), were independent risk factors for FM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The HALP score, a simple composite index derived from routine blood tests, demonstrates significant value for the diagnosis, severity stratification, and prognosis prediction of pediatric fulminant myocarditis. It serves as a useful adjunct to conventional cardiac markers and may aid in early identification of high-risk patients requiring intensive care.\u003c/p\u003e","manuscriptTitle":"A Novel Evaluation Indicator for Pediatric Fulminant Myocarditis: Diagnostic and Prognostic Value of the HALP Score","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 16:52:25","doi":"10.21203/rs.3.rs-8832543/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-02T07:47:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T11:57:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227943285434589677881668015187985390510","date":"2026-02-28T08:10:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T17:43:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322076302834882395615596868485746407471","date":"2026-02-25T02:18:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237677986153747460150091671696528006058","date":"2026-02-23T07:28:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T06:16:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323899617349054392725361665834142243837","date":"2026-02-23T00:34:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200401451462237250418327039404852686886","date":"2026-02-22T17:01:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332472541660799747460402134156834672990","date":"2026-02-20T14:01:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119680158684282692139765398825617037528","date":"2026-02-20T13:02:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-20T11:34:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T11:32:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T10:11:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-12T09:46:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-02-12T09:38:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7fc6668e-7e8e-4328-9088-8fa9a02b18d0","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:12:31+00:00","versionOfRecord":{"articleIdentity":"rs-8832543","link":"https://doi.org/10.1186/s12887-026-06820-8","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-04-02 15:59:09","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2026-02-25 16:52:25","video":"","vorDoi":"10.1186/s12887-026-06820-8","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06820-8","workflowStages":[]},"version":"v1","identity":"rs-8832543","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8832543","identity":"rs-8832543","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}