Find information on thousands of medical conditions and prescription drugs.


In medicine (cardiology), myocarditis is inflammation of the myocardium, the muscular part of the heart. It is generally due to infection (viral or bacterial). It may present with rapid signs of heart failure. more...

Mac Ardle disease
Macular degeneration
Mad cow disease
Maghazaji syndrome
Mal de debarquement
Malignant hyperthermia
Mallory-Weiss syndrome
Malouf syndrome
Marburg fever
Marfan syndrome
MASA syndrome
Mast cell disease
MAT deficiency
Maturity onset diabetes...
McArdle disease
McCune-Albright syndrome
Mediterranean fever
Megaloblastic anemia
Meleda Disease
Meniere's disease
Mental retardation
Mercury (element)
Metabolic acidosis
Metabolic disorder
Methylmalonic acidemia
Microscopic polyangiitis
Microtia, meatal atresia...
Miller-Dieker syndrome
Mitochondrial Diseases
Mitral valve prolapse
Mobius syndrome
MODY syndrome
Moebius syndrome
Molluscum contagiosum
MOMO syndrome
Mondini Dysplasia
Mondor's disease
Monoclonal gammopathy of...
Morquio syndrome
Motor neuron disease
Moyamoya disease
MPO deficiency
Mullerian agenesis
Multiple chemical...
Multiple endocrine...
Multiple hereditary...
Multiple myeloma
Multiple organ failure
Multiple sclerosis
Multiple system atrophy
Muscular dystrophy
Myalgic encephalomyelitis
Myasthenia gravis
Mycosis fungoides
Myelodysplastic syndromes
Myeloperoxidase deficiency
Myoadenylate deaminase...
Myositis ossificans

Signs and symptoms

The signs and symptoms associated with myocardits are varied, and relate either to the actual inflammation of the myocardium, or the weakness of the heart muscle that is secondary to the inflammation. Signs and symptoms of myocarditis include:

  • Sudden death (in young adults, myocarditis causes up to 20% of all cases of sudden death)
  • Congestive heart failure (leading to edema, breathlessness and hepatic congestion)
  • Palpitations (due to Arrhythmias)
  • Chest pain
  • Fever (especially when infectious, e.g. in rheumatic fever)

Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent with a recent viral infection, including fever, joint pains, and easy fatigueability.

Myocarditis is often associated with pericarditis, and many patients present with signs and symptoms that suggest concurrent myocarditis and pericarditis.


Myocardial inflammation can be suspected on the basis of electrocardiographic results (ECG), elevated CRP and/or ESR and increased IgM (serology) against viruses known to affect the myocardium. Markers of myocardial damage (troponin or creatine kinase cardiac isoenzymes) are elevated.

The ECG findings most commonly seen in myocarditis are diffuse T wave inversions, without shifts in the ST segment.

The gold standard is still biopsy of the myocardium, generally done in the setting of angiography. A small tissue sample of the endocardium and myocardium is taken, and investigated by a pathologist by light microscopy and - if necessary - immunochemistry and special staining methods. Histopathological features are: myocardial interstitium with abundant edema and inflammatory infiltrate, rich in lymphocytes and macrophages. Focal destruction of myocytes explains the myocardial pump failure.


A large number of different causes have been identified as leading to myocarditis:

  • Infectious:
    • Viral (e.g. Coxsackie virus, rubella virus, polio virus, cytomegalovirus, possibly hepatitis C)
    • Bacterial (e.g. brucella, Corynebacterium diphtheriae, gonococcus, Haemophilus influenzae, Tropheryma whipplei, and Vibrio cholerae).
    • Spirochetal (Borrelia burgdorferi and leptospirosis)
    • Protozoal (Toxoplasma gondii and Trypanosoma cruzi)
    • Fungal (e.g. actinomyces, aspergillus)
    • Parasitic: ascaris, Echinococcus granulosus, Paragonimus westermani, schistosoma, Taenia solium, Trichinella spiralis, visceral larva migrans, and Wuchereria bancrofti
    • Rickettsial
  • Immunological:
    • Allergic (e.g. acetazolamide, amitriptyline)
    • Rejection after a heart transplant
    • Autoantigens (e.g. in Churg-Strauss syndrome, Wegener's granulomatosis)
  • Toxic:
    • Drugs (e.g. anthracyclines and some other forms of chemotherapy, ethanol, and antipsychotics, e.g. clozapine)
    • Toxins (e.g. arsenic, carbon monoxide, snake venom)
    • Heavy metals (e.g. copper, iron)
  • Physical agents (electric shock, hyperpyrexia, and radiation)

Bacterial myocarditis is rare in patients without immunodeficiency. Myocardial damage due to chemotherapy, most notably the class of anthracycline drugs, is fairly common.


[List your site here Free!]

Myocarditis outbreak among adults, Illinois, 2003
From Emerging Infectious Diseases, 10/1/05 by Gregory D. Huhn

An outbreak of myocarditis occurred among adults in Illinois in 2003. Diagnostic testing of myocardial tissues from 3 patients and comprehensive tests for enterovirus and adenovirus of other specimens from patients were inconclusive. Appropriate specimen collection from patients with idiopathic cardiomyopathy and further enhancement of diagnostic techniques are needed.


A cute myocarditis is characterized by inflammatory infiltrates of the myocardium. Disease has been attributed to multiple infectious and noninfectious causes, but viruses, particularly the enteroviruses group B coxsackievirus and echoviruses, are believed to be the most common agents of infection in the United States (1). An infectious cause of myocarditis is usually suspected when unexplained heart failure or arrhythmia occurs in a person with a systemic febrile illness or upper respiratory tract infection. Acute myocarditis is typically sporadic, although clusters have been reported during outbreaks of viral disease (2,3). Most cases are idiopathic without a known cause (1). Myocardial biopsy specimens used for pathologic examination, the conventional standard for diagnosis (4,5), have been considered difficult to collect in nonfatal cases. Viruses are infrequently cultured from tissue specimens, although viral nucleic acid identification by polymerase chain reaction (PCR) assays on myocardium has recently enhanced viral detection (6-8). Viral serologic tests and PCR assays of blood, stool, urine, and nasopharyngeal specimens are adjunctive techniques for diagnosing myocarditis that have not been validated.

On March 21, 2003, the Kane County Health Department was notified about 6 cases of presumptive myocarditis and 1 case of pericarditis that occurred in patients hospitalized in Kane County, Illinois, within a 2-week period from February 26 to March 10. Five case-patients were <50 years of age, 1 of whom died within 24 hours of hospitalization. Five of the 6 case-patients were hospitalized at hospital A. Illinois Department of Public Health (IDPH) and Kane County Health Department initiated an investigation to identify additional cases and determine the cause of illness.

The Study

On March 22, IDPH distributed a notice describing the cluster of myocarditis cases to local health departments and healthcare providers in Illinois and requested urgent reporting of similar cases. At hospital A, where most of the initial cases were diagnosed, active surveillance was instituted for patients with a clinical syndrome consistent with myocarditis or pericarditis or an upper respiratory tract illness with profound fatigue or disproportionate shortness of breath of [greater than or equal to] 2 weeks' duration. For patients with suspected cases, a testing protocol was implemented, which included a 2-dimensional echocardiogram; electrocardiogram; chest radiograph; measure of serum cardiac enzymes; complete blood count; nasopharyngeal, stool, and urine samples for enterovirus assays; and acute- and convalescent-phase serologic testing for enterovirus.

A review of all records for patients with discharge diagnoses of myocarditis or cardiomyopathy at all 5 hospitals in Kane County from October 1, 2002, through March 31, 2003, was conducted to find unreported cases of myocarditis. Persons with ischemic, alcoholic, postpartum, or chronic cardiomyopathy were excluded. To determine the background number of myocarditis cases for all patients <50 years of age in Kane County, a database search of medical records during the preceding 2-year period (October 1, 2000 to September 30, 2002) at all 5 hospitals was performed by principal International Classification of Diseases, 9th revision (ICD-9) discharge diagnosis codes (Appendix).

A case of myocarditis was defined as 1) a person with myocarditis diagnosed by electrocardiogram, echocardiogram, or cardiac catheterization, which indicates the presence of unexplained arrhythmia or decreased ejection fraction without apparent cause or 2) myocardial inflammatory infiltrates on tissue pathologic examination by using the Dallas criteria (9) or 3) viral isolation or nucleic acid identification in myocardial tissue specimens in persons living in northern Illinois from October 1, 2002, through May 30, 2003.

Medical records of patients were reviewed, and physicians who treated case-patients were interviewed when available. Information was collected about patient demographics; antecedent illness; underlying medical condition; exposure to toxins, pets, or ill persons; recent travel; and smallpox vaccination history.

The results of echocardiograms and routine specialized laboratory tests, including enterovirus complement-fixation serologic screening, conducted by physicians who evaluated patients at hospitals, were recorded. Nasopharyngeal, urine, and stool specimens from patients were cultured for enterovirus at the IDPH laboratory. Any available serum and myocardial tissue specimens from patients were tested at the California Department of Health Services Viral and Rickettsial Disease Laboratory by using real-time PCR nucleic acid amplification (Amersham Eclipse, Piscataway, NJ, USA) and immunoglobulin M (IgM) enzyme immunoassay for detecting enterovirus and adenovirus (10,11).

Pathology reports on autopsy specimens from patients with fatal cases and myocardial biopsy specimens from patients with nonfatal cases were reviewed. Formalin-fixed, paraffin-embedded tissue from the autopsy of 1 available patients was submitted to the Centers for Disease Control and Prevention (CDC) Unexplained Deaths and Critical Illnesses (UNEX) Laboratory for Gram and calcium staining, enteroviral 5' noncoding region gene PCR assay, and immunohistochemical staining to detect enterovirus, cytomegalovirus, influenza A, influenza B, and hantavirus.

Sixteen cases, 1 of which (that of patient 8) was recognized through retrospective medical record review, were identified. All patients were hospitalized and admitted between January 28 through April 7 (Figure 1), and 13 patients (81%) were adults <50 years of age. Six (38%) of the 16 patients were hospitalized at hospital A during January through March. For comparison, the number of diagnoses of myocarditis in patients <50 years of age (16 patients) from October 1, 2000, to September 30, 2002, was <1 per month.


The median age for patients was 38 years (range 20-70 years). Among the 16 case-patients, 4 (25%) were residents of Kane County, 8 (50%) were from 5 counties bordering Kane County, and 4 (25%) were from 4 other counties in northern Illinois (Figure 2).


Thirteen case-patients (81%) had an acute, viral-like illness within 1 month before onset of myocarditis. Two female patients, 26 and 39 years of age, had ventricular fibrillation that required an automatic implantable cardioverter defibrillator (AICD) and recovered. There were 2 deaths (see online Table 1, available at http://www.cdc. gov/ncidod/EID/vol 11 no 10/04-1152.htm#table 1).

No common exposures could be identified among the patients. None of the patients had recently been vaccinated for smallpox.

Information on acute serologic testing for group B coxsackievirus performed at hospitals was known for 5 patients. Two patients (patients 11 and 14) had elevated antibody titers to group B coxsackievirus. Patient 14 had a convalescent-phase serum specimen collected for group B coxsackievirus antibody testing that had a 2-fold greater titer than the acute-phase sample. Acute serologic testing for echovirus was performed for 2 patients; results were positive for patient 14 and negative for patient 13. Patient 14 also had an elevated acute-phase influenza B antibody titer but a negative convalescent-phase antibody titer. Patient 12 had no change in acute- and convalescent-phase-positive titers for group B coxsackievirus (online Table 2, available at vol11no10/04-1152.htm#table2).

IDPH laboratory cultured nasopharyngeal (n = 5), urine (n = 6), stool (n = 6), and myocardial tissue (n = 1) specimens from 9 patients for enterovirus viral isolation. All cultures were negative. Among specimens (serum samples from 11 patients and myocardial tissue from 2 patients) tested for enterovirus and adenovirus by PCR and enzyme immunoassay, all were negative (online Table 2).

For the 2 patients with fatal cases, the primary autopsy diagnosis was acute myocarditis. Autopsy tissue specimens from the 1 case-patient submitted to CDC were negative for viral agents (patient 1).


An outbreak of myocarditis of unknown cause occurred among adults in Kane County (population 400,000) and adjacent areas during winter and early spring 2003. Surveillance for myocarditis cases was initiated throughout Illinois in March and April, although clustering of cases was only evident in and limited to Kane County and surrounding communities. The reporting of myocarditis cases from other counties likely reflected baseline rates of idiopathic myocarditis in those populations that only came to the attention of public health officials through enhanced surveillance.

No common exposures were identified among case-patients. The outbreak occurred within the same period that adverse events of myopericarditis were being reported after smallpox vaccinations among military and healthcare personnel in the United States, including Illinois (12); however, no patients in this outbreak had recently been vaccinated against smallpox. Most illnesses were preceded by a prodrome that suggested the outbreak was viral in origin. Substantial illness and death occurred in these reported cases. All reported patients were hospitalized, 2 required AICD devices, and 2 deaths occurred, a reminder of the severe sequelae associated with this illness.

Despite extensive laboratory testing on submitted specimens, no specific agent was identified. Cross-reactivity of group B coxsackievirus serology with several agents was apparent from initial laboratory tests performed at the hospitals. These results were insufficient to support a specific cause of illness. Tissue specimens from only 3 of the 16 patients were available for testing, which was a major laboratory limitation in the investigation, particularly for detecting viral nucleic acid by PCR assays. The inability to implicate a responsible agent is a common outcome of myocarditis outbreak investigations (1,13).

A better understanding of myocarditis through enhanced diagnostic and therapeutic strategies, increased awareness of possible clusters of illness, and rapid reporting of clusters to public health departments will help improve prevention of future outbreaks. Recent biopsy-based studies suggest that a proportion of life-threatening myocarditis or idiopathic cardiomyopathy in otherwise healthy adults may arise from enteroviral and cytomegalovirus infections (14,15). Research is needed to assess the effect of potential antiviral treatment on illness and death in this patient population. In addition to encouraging appropriate viral testing of acute- and convalescent-phase serologic specimens, further study is required to examine the usefulness of endomyocardial tissue collection for advanced molecular analyses in patients with unexplained cardiomyopathy.


Selected Codes for Myocarditis and Pericarditis from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).

Myocarditis: 422.90, 422.92, 422.93,422.99

Other primary cardiomyopathies: 42.4


We thank Julu Bhatnagar, Marc Fischer, Andrea Winquist, and Carol Glaser for their contributions to this study and acknowledge the activities of CDC's UNEX Project and CDC's Division of Viral and Rickettsial Diseases Infectious Disease Pathology Laboratory.

We note with sadness that one of our coauthors, Douglas Passaro, died suddenly on April 18, 2005. Dr Passaro was a talented and outstanding researcher, who initiated a nationally recognized program in the 1990s to investigate infectious causes of unexplained deaths; ironically, his death also remains unexplained.


(1.) Savoia MC, Oxman MN. Myocarditis and pericarditis. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 5th ed. Philadelphia: Churchhill Livingstone; 2000. p. 925-41.

(2.) Woodruff JF. Viral myocarditis: a review. Am J Pathol. 1980; 101:427-84.

(3.) Helin M, Sarola J, Lapinleimu K. Cardiac manifestations during a Coxsackie B5 epidemic. BMJ. 1968;3:97.

(4.) Billingham ME. The safety and utility of endomyocardial biopsy in infants, children, and adolescents. J Am Coil Cardiol. 1990; 15:443-5.

(5.) Fowles RE, Mason JW. Endomyocardial biopsy. Ann Intern Med. 1982;97:885-94.

(6.) Katsuragi M, Yutani C, Mukai, T. Arai Y, Imakita M, Ishibashi-Ueda H, et al. Detection of enteroviral genome and its significance in cardiomyopathy. Cardiology. 1993;83:4-13.

(7.) Severini GM, Mestroni L, Falaschi A, Camerini F, Giacca M. Nested polymerase chain reaction for high-sensitivity detection of enteroviral RNA in biological samples. J Clin Microbiol. 1993;31:1345-9.

(8.) Tracy S, Wiegand V, McManus B, Gauntt C, Pallansch M, Beck M, et al. Molecular approaches to enteroviral diagnosis in idiopathic cardiomyopathy and myocarditis. J Am Coil Cardiol. 1990; 15:1688-94.

(9.) Aretz HT. Myocarditis: the Dallas criteria. Hum Pathol. 1987;18:619-24.

(10.) Rotbart HA, Sawyer MH, Fast S, Lewinski C, Murphy N, Keyser EF, et al. Diagnosis of enteroviral meningitis by using PCR with a colorimetric microwell detection assay. J Clin Microbiol. 1994;32:2590-2.

(11.) Schnurr D, Yagi S, Devlin R. IgA and IgM ELISA for the study of an echovirus 30 outbreak in California [abstract S23]. In: Programs and abstracts of the 10th Annual Clinical Virology Symposium. Clearwater (FL): Pan American Society for Clinical Virology; 1994.

(12.) Centers for Disease Control and Prevention. Cardiac adverse events following smallpox vaccination--United States, 2003. MMWR Morb Mortal Wkly Rep. 2003;52:248-50.

(13.) Mounts AW, Amr S, Jamshidi R, Groves C, Dwyer D, Guarner J, et al. A cluster of fulminant myocarditis cases in children, Baltimore, Maryland, 1997. Pediatr Cardiol. 2001;22:34-9.

(14.) Kuhl U, Pauschinger M, Noutsias M, Seeberg B, Bock T, Lassner D, et al. High prevalence of viral genomes and multiple viral infections in the myocardium of adults with "idiopathic" left ventricular dysfunction. Circulation. 2005; 111:887-93.

(15.) Kyto V, Vuorinen T, Saukko P, Lautenschlager I, Lignitz E, Saraste A, et al. Cytomegalovirus infection of the heart is common in patients with fatal myocarditis. Clin Infect Dis. 2005;40:683-8.

Gregory D. Huhn, * ([dagger]) Cindy Gross, ([double dagger]) David Schnurr, ([section]) Chris Preas; ([section]) Shigeo Yagi, ([section]) Sarah Reagan, * Chris Paddock, * Douglas Passaro, ([paragraph]) and Mark S. Dworkin ([dagger])

* Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ([dagger]) Illinois Department of Public Health, Chicago, Illinois, USA; ([double dagger]) Kane County Health Department, Aurora, Illinois, USA; ([section]) California Department of Health Services, Richmond, California, USA; and ([paragraph]) University of Illinois, Chicago, School of Public Health, Chicago, Illinois, USA

Dr Huhn completed an infectious diseases fellowship at Rush University Medical Center, Chicago, Illinois, in June 2005. From 2002 to 2004, he was an Epidemic Intelligence Service officer with CDC. His research interests include emerging infectious diseases, tropical medicine, infection control, and HIV.

Address for correspondence: Gregory D. Huhn, Rush University Medical Center, Division of Infectious Diseases, 600 S Paulina St, Suite 140 AC.FAC, Chicago, IL 60612, USA; fax: 312-942-8200; email:

COPYRIGHT 2005 U.S. National Center for Infectious Diseases
COPYRIGHT 2005 Gale Group

Return to Myocarditis
Home Contact Resources Exchange Links ebay