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•  Etiological Agents Causing Myocarditis
•   Viral (Most Common)  
•  Adenovirus  
•  Coxsackie virus/Enterovirus   
• Cytomegalovirus   
• Parvovirus B19   
• Hepatitis C virus  
•  Influenza   
• Human immunodeficiency virus   
• Herpes virus  
•  Epstein-Barr virus   
• Mixed infections    

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• Bacterial   
• Mycobacterial species   
• Chlamydia pneumoniae  
•  Streptococcal species   
• Mycoplasma pneumoniae   
• Treponema pallidum  
• Fungal   
• Aspergillus   
• Candida  
•  Coccidioides   
• Cryptococcus   
• Histoplasma   
• Protozoal   Trypanosoma cruzi   
• Parasitic   Schistosomiasis   Larva migrans   

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• Toxins   
• Anthracyclines   
• Cocaine   
• Hypersensitivity   
• Clozapine   
• Sulfonamides   
• Cephalosporins   
• Penicillins   
• ricyclic antidepressants   

• Autoimmune Activation
•   Smallpox vaccination  
•  Giant cell myocarditis  
• Churg-Strauss syndrome   
• Sjögren syndrome
•  Inflammatory bowel disease   
• Celiac disease  
•  Sarcoidosis   
• Systemic lupus erythematosus   
• Takayasu arteritis   
• Wegener granulomatosis

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•     Expanded Criteria for Diagnosis of
  Myocarditis
• Suspicious for myocarditis 2 positive
  categoriesCompatible with myocarditis 3
  positive categories
• High probability of being myocarditis all 4
  categories positive(Any matching feature in
  category positive for category)  
• Category I Clinical Symptoms   
• Clinical heart failure   
• Fever  
•  Viral prodrome  
•  Fatigue
•  Dyspnea on exertion   
• Chest pain   
• Palpitations  
•  Presyncope or syncope    

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• Category II Evidence of Cardiac
  Structural/Functional Perturbation in the Absence
  of Regional Coronary Ischemia  
•  Echocardiography evidence   
• Regional wall motion abnormalities  
•  Cardiac dilation   
• Regional cardiac hypertrophy   
• Troponin release   High sensitivity (gt0.1 ng/ml)
    
• Positive indium-111 antimyosin scintigraphy   and
    Normal coronary angiography or   Absence of
  reversible ischemia by coronary distribution on
  perfusion scan

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• Category III Cardiac Magnetic Resonance Imaging
    I
• ncreased myocardial T2 signal on inversion
  recovery sequence  
•  Delayed contrast enhancement following
  gadolinium-DTPA infusion   
• Category IV Myocardial BiopsyPathological or
  Molecular Analysis   
• Pathology findings compatible with Dallas
  criteria   
• Presence of viral genome by polymerase chain
  reaction or in situ hybridization

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• Comparison of Efficacy of Various Diagnostic
  Modalities for Myocarditis
• Diagnostic Modality Sensitivity
  Range Specificity Range
• ECG changes (e.g., AV block, Q, ST
  changes) 47 ?
• Troponin (lower threshold of gt0.1
  mg/ml) 34-53 89-94
• CK-MB 6 ?
• Antibodies to virus or myosin 25-32 40
• Indium-111 antimyosin scintigraphy 85-91 34-53
  
• Echocardiography (ventricular dysfunction) 69 ?
• Cardiac magnetic resonance imaging 86 95
• Myocardial biopsy (Dallas criteria of
  pathology) 35-50 78-89
• Myocardial biopsy (viral genome by
  PCR) 38-65 80-100
• ? indeterminant or poor AV atrioventricular
  CK-MB cytosine kinase isoenzyme ECG
  electrocardiogram PCR polymerase chain
  reaction.

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