ACUTE MYOCARDITIS

This is an acute inflammatory condition that may complicate a wide variety of infections;
inflammation may be due to infection of the myocardium or the effects of circulating toxins.
Viral infection is the most common cause and the main culprits are the Coxsackie viruses (35
cases per 1000 infections) and influenza viruses A and B (25 cases per 1000 infections).
Myocarditis may occur several weeks after the initial viral infection and susceptibility is
increased by corticosteroid treatment, immunosuppression, radiation, previous myocardial
damage and exercise. Some bacterial and protozoal infections may be complicated by
myocarditis; for example, approximately 5% of patients with Lyme disease (Borrelia
burgdorferi,) develop myopericarditis, which is often associated with variable degrees of
atrioventricular block.

The clinical picture ranges from a symptomless disorder, sometimes recognised by the presence
of an inappropriate tachycardia or abnormal ECG, to fulminant heart failure. Myocarditis may be
heralded by a 'flu'-like illness. ECG changes are common but non-specific. Biochemical markers
of myocardial injury (e.g. troponin I and T, creatine kinase) are elevated in proportion to the
extent of damage. Echocardiography may reveal left ventricular dysfunction which is sometimes
regional (due to focal myocarditis), and if the diagnosis is uncertain it can be confirmed by
endomyocardial biopsy.

SPECIFIC DISEASES OF HEART MUSCLE

Many forms of specific heart muscle disease produce a clinical picture that is indistinguishable
from dilated cardiomyopathy (e.g. connective tissue disorders, sarcoidosis, haemochromatosis,
alcoholic heart muscle disease,). In contrast, amyloidosis and eosinophilic heart disease
produce symptoms and signs similar to those found in restrictive or obliterative
cardiomyopathy, whereas the heart disease associated with Friedreich's ataxia) can mimic
hypertrophic cardiomyopathy.

Treatment and prognosis are determined by the underlying disorder. Abstention from alcohol
may lead to a dramatic improvement in patients with alcoholic heart muscle disease.
 18.132 SPECIFIC DISEASES OF HEART MUSCLE
Infections
Viral, e.g. Coxsackie A and B, influenza, HIV

Bacterial, e.g. diphtheria, Borrelia burgdorferi

Protozoal, e.g. trypanosomiasis

Endocrine and metabolic disorders

e.g. Diabetes, hypo- and hyperthyroidism, acromegaly, carcinoid

syndrome, phaeochromocytoma, inherited storage diseases

Connective tissue diseases

e.g. Systemic sclerosis, systemic lupus erythematosus (SLE),
polyarteritis nodosa

Infiltrative disorders
e.g. Haemochromatosis, haemosiderosis, sarcoidosis, amyloidosis

Toxin

e.g. Doxorubicin, alcohol, cocaine, irradiation

Neuromuscular disorders

e.g. Dystrophia myotonica, Friedreich's ataxia

CARDIAC TUMOURS
Primary cardiac tumours are rare (< 0.2% of autopsies), but the heart and mediastinum may be
the site of metastases.

Most primary tumours are benign (75%), and of these the majority are myxomas. The remainder
are fibromas, lipomas, fibroelastomas and haemangiomas.

ATRIAL MYXOMA
Myxomas most commonly arise in the left atrium as single or multiple polypoid tumours,
attached by a pedicle to the interatrial septum. They are usually gelatinous but may be solid and
even calcified, with superimposed thrombus.
The tumour may be detected incidentally on echocardiography, or following investigation of
pyrexia, syncope, arrhythmias or emboli. Occasionally, the condition presents with malaise and
features suggestive of a connective tissue disorder, including a raised ESR.
On examination the first heart sound is usually loud, and there may be a murmur of mitral
regurgitation with a variable diastolic sound (tumour 'plop') due to prolapse of the mass through
the mitral valve.
The diagnosis is made on echocardiography and treatment is by surgical excision. If the pedicle
is removed, fewer than 5% of tumours recur.