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Myocarditis

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...

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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.

Diagnosis

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.

Causes

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.

Read more at Wikipedia.org


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Managing life threatening viral myocarditis with dilated cardiomyopathy by Drotrecogin alfa and circulatory assisted devices
From CHEST, 10/1/05 by Tsung P. Tsai

PURPOSE: Acute fulminant myocarditis with dilated cardiomyopathy caused by Parvovirus B19 may present with cardiogenic shock refractory to the maximum dose of inotropics and intra-aortic balloon pumping (IABP). The benefits of extracorporeal membrane oxygenation (ECMO) support for patients with life-threatening myocarditis has been established. Drotrecogin alfa, recombinant human activated protein C, has antithrombotic, anti-inflammatory and profibrinolytic properties. The effectiveness from the circulatory support (ECOM or IABP) and activated PaurOtein C use in managing acute myocarditis with dilated cardiomyopathy caused by Parvovirus B19 has to be defined.

METHODS: Four patients (2 male, 2 female, mean age 37.2 years) presented with congestive heart failure 3 to 4 days after flu-like symptoms (intermittent fever 38-39 [degrees]C, dyspnea and chest tightness). Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. EKG revealed non-specific ST wave changes. 2-D echocardiograms demonstrated severe myocardial dysfunction with LVEF, measured between 18.4 to 22% (mean, 19.5%). Coronary angiography was performed in each patient and excluded ischemic heart disease. Acute decompensation with more than 2 organ Failure (heart and lungs) and unresponsive to more than 2 inotropics and acute respiratory therapy were indications for the use of circulatory support by IABP (3pts) and/or ECMO (3pts) as well as activated protein C (3pts). Serological test and myocardial biopsy for Parvovirus B19 was positive in 3 pts and one pt, respectively.

RESULTS: All three pts with ECMO and IABP support were weaned. Follow-up LVEF measured were 53%, 53%, 55% and 60%, respectively. However one pt died one month later because the deterioration of her SLE condition and repeated infection. There were no neurologic sequelae in survivors.

CONCLUSION: Use of circulatory support and activated protein C is an effective alternative for treating life-threatening viral myocarditis with dilated cardiomyopathy, especially caused by Parvovirus B19 virus.

CLINICAL IMPLICATIONS: Parvovirus B19virus can cause severe myocarditis with dilated cardiomyopathy and circulatory collapse. Combined use of Drotrecogin alfa and ECMO and/or IABP is an effective novel therapy for this cohort of patients.

DISCLOSURE: Tsung Tsai, None.

Tsung P. Tsai PhD * Shyh M. Tsao MD Yi L. Wu MD Jung M. Yu MD Kuei C. Chan MD Kwo C. Ueng MD Chung Shan Medical University Hospital, Taichung, Taiwan ROC

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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