Myocarditis

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Myocarditis
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Myocarditis

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

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Important Causes of Myocarditis

• Infection
• Viral
• Bacterial, rickettsial, spirochetal
• Protozoal, Metazoal
• Fungal
• Toxic
• anthracyclines, catecholamines, Interleukin-2,
  alpha 2 interferon
• Hypersensitivity

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Viral Infection

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

• Rubella
• Rubeola
• Vaccinia
• Coronavirus
• Rabis
• Hepatitis B
• Arbovirus
• Junin virus
• Human immunodeficiency

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Bacterial, rickettsial, spirochetal

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

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

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Protozoal, Metazoal, Fungal

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

• Fungal
• Aspergillosis
• Blastomycosis
• Candidiasis
• Coccidioidomycosis
• Cryptococcosis
• Histoplasmosis
• Mucormycosis

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Drugs Causing Hypersensitivity Myocarditis

• Antibioticsamphoericin Bampicillinchloramphenic
  olpenicillintetracyclinestreptomycin
• Sulfonamidessufadiazinesufisoxazole

• Anticonvulsantsphenindionephenytoincarbamazepin
  e
• Antitubercuousisoniazidparaaminosalicylate
• Anti-inflammatoryindomethacinoxyphenbutazonephe
  nylbutazone

Diureticsacetazolamidechlorthalidonehydrochloro
thiazidespironolactone Otheramitriptylinemethyl
dopasulfonylureastetanus toxoid
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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

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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

JAMA 1986 2562696-2699
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Blood studies

• Sed rate elevation 60
• White count elevation 25
• CK-MB elevation 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

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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

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Myocarditis
H9925 9-8-98
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H9925 8-30-98
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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

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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 myocarditisan
  inflammatory infiltrate of the myocardium with
  necrosis and/or degeneration of adjacent myocytes
  not typical of the ischemic changes associated
  with coronary artery disease

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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

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Myocardial Treatment Trial111 patients with
active myocarditis

• Age 42 ? 14 years
• Sex 62 male
• Ejection fraction 0.24 ? 0.10
• Chest pain 35
• Increase MB-CK 12
• Flulike symptoms 59
• Increased ESR 61
• Elevated WBC 24
• Fever 18

Circulation 199184(suppl II)II-2
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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