Myocarditis

11/98

medslides.com

Myocarditis
Definition: any inflammation or
degeneration of the heart
Autopsy
Endomyocardial biopsy
may provide greater insight into the
pathogenesis, etiology, and treatment

11/98

medslides.com

Important Causes of Myocarditis

Infection

Viral
Bacterial, rickettsial, spirochetal
Protozoal, Metazoal
Fungal

Toxic
anthracyclines, catecholamines, Interleukin-2, alpha
interferon

Hypersensitivity
11/98

medslides.com

Viral Infection

Coxsackie (A, B)
Echo
Influenza (A, B)
Polio
Herpes simplex
Varicella-zoster
Epstein-Barr
Cytomegalovirus
Mumps

11/98

Rubella
Rubeola
Vaccinia
Coronavirus
Rabis
Hepatitis B
Arbovirus
Junin virus
Human immunodeficiency
medslides.com

Bacterial, rickettsial, spirochetal

Corynebacterium
diphtheriae
salmonella typhi
Beta-hemolytic streptococci
Neisseria meningitidis
Legionella pneumophila
Listeria monocytogenes
Camphylobacter jejuni
Coxiella burnetii (Q fever)
11/98

Chlamydia trachomatis
Mycoplasma pneumoniae
Chlamydia psittaci
(psittacosis)
Rickettsia rickettsii (Rocky
Mountain spotted fever)
Borrelia burgdorferi (Lyme
disease)
Mycobacterium
tuberculosis
medslides.com

Protozoal, Metazoal, Fungal

Protozoal
Trypnosoma cruzi (Chagas
disease)
Toxoplasma gondi
Metazoal
Trichinosis
Ehinococcosis

11/98

Fungal
Aspergillosis
Blastomycosis
Candidiasis
Coccidioidomycosis
Cryptococcosis
Histoplasmosis
Mucormycosis

medslides.com

Drugs Causing
Hypersensitivity Myocarditis
Anticonvulsants
Diuretics
Antibiotics
phenindione
acetazolamide
amphoericin B
phenytoin
chlorthalidone
ampicillin
carbamazepine
hydrochlorothiazide
chloramphenicol
Antitubercuous
spironolactone
penicillin
isoniazid
tetracycline
Other
paraaminosalicylate
streptomycin
amitriptyline
Anti-inflammatory
methyldopa
Sulfonamides
indomethacin
sulfonylureas
sufadiazine
oxyphenbutazone
tetanus toxoid
sufisoxazole
phenylbutazone
11/98

medslides.com

Clinical Manifestations

Most cases of acute myocarditis are clinically silent

60% of pts had antecedent flulike symptoms
Large number identified by heart failure symptoms
35% of pts with myocarditis and HF have chest pain
May mimic an acute MI with ventricular dysfunction,
ischemic chest pain, ECG evidence of injury or Q
waves

11/98

medslides.com

Clinical Manifestations
May present with syncope, palpitation with AV block
or ventricular arrhythmia
May cause sudden death
myocarditis found at autopsy in 20% of Air Force recruits
with sudden death*

May present with systemic or plumonary

thromboembolic disease

11/98

JAMA 1986; 256:2696-2699

medslides.com

Blood studies
Sed rate elevation
White count elevation
CK-MB elevation

60%
25%
12%

a 4 fold rise in IgG titer over a 4-6 wk period is

required to document an acute viral infection
Heart specific antibodies are nonspecific for
myocarditis; also found in dilated cardiomyopathy
11/98

medslides.com 10

Electrocadiogram

sinus tachycardia is most common

diffuse ST-T wave changes
myocardial infarction pattern
conduction delay and LBBB in 20%
complete heart block causing Stokes-Adams
attacks (particularly in Japan), but rarely require a
permanent pacer
supraventricular and ventricular arrhythmias
11/98

medslides.com 11

Myocarditis

11/98

H9925 9-8-98

medslides.com 12

11/98

H9925 8-30-98

medslides.com 13

Echocardiography
Useful tool in managing patients with
acute myocarditis
LV systolic dysfuntion is common with
segmental wall motion abnormalities
LV size is typically normal or mildly dilated
wall thickness may be increased
ventricular thrombi detected in 15%
11/98

medslides.com 14

Endomyocardial Biopsy
RV bioptome permit repetitive sampling
biopsy should be applied early after onset
of symptoms to maximize yield - resolution
may be seen in four days on serial biopsies
Dallas criteria for active myocarditis
an inflammatory infiltrate of the myocardium with necrosis
and/or degeneration of adjacent myocytes not typical of the
ischemic changes associated with coronary artery disease
11/98

medslides.com 15

Imaging Studies
Gallium 67 (avid for inflammation) showed promise
for screening active myocarditis
Indium 111-antimyosin monoclonal antibody (avid
for injured myocardium)
sensitivity 83%
specificity 53%
+ predictive value 92%
endomyocardial biopsy remains the diagnostic
standard
11/98

medslides.com 16

Myocardial Treatment Trial

111 patients with active myocarditis
Age
Sex
Ejection fraction
Chest pain
Increase MB-CK
Flulike symptoms
Increased ESR
Elevated WBC
Fever
11/98

42 14 years
62% male
0.24 0.10
35%
12%
59%
61%
24%
18%

Circulation 1991;84(suppl II):II-2

medslides.com 17

Treatment
majority of patients have a self-limited disease
management of LV dysfunction similar to other
forms of congestive heart failure
? exercise may intensify inflammatory response
consider anticoagulation to prevent thromboemboli
consider temporary pacer for complete AV block
? prednisone and azathioprine - no apparent
benefit seen in the Myocarditis Treatment Trial
11/98

medslides.com 18