Myocarditis 3

7/23/2019 Myocarditis 3

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MYOCARDITISMyocarditis is collection of diseases of

infectious, toxic, and autoimmune etiologiescharacterized y in!ammation of the heart"

Suse#uent myocardial destruction can leadto dilated cardiomyo$athy"



Dallas Classification (1987) Initial BiopsyMyocarditis% Myocardial necrosis, degeneration, or oth,

in the asence of signi&cant coronary artery disease 'ithad(acent in!ammatory in&ltrate 'ith or 'ithout &rosis"

)orderline myocarditis% In!ammatory in&ltrate too s$arseor myocyte damage not a$$arent"

*o myocarditis

Subsequent Biopsies

Ongoing +$ersistent myocarditis 'ith or 'ithout &rosis"Resol-ing +healing myocarditis 'ith or 'ithout &rosis"

Resol-ed +healed myocarditis 'ith or 'ithout &rosis"



CAUSESAmongst the infectious causes, -iral acute

myocarditis is y far the most common"

Identi&cation of the coxsac.ie/adeno-irus

Other -iruses im$licated in myocarditisinclude in!uenza -irus, echo-irus,her$es sim$lex -irus, -aricella/zoster

-irus, he$atitis, 0$stein/)arr -irus, andcytomegalo-irus"

1uman immunode&ciency -irus +1I2



CAUSES*on-iral infectious causes are numerous and -aried"

)acteria% chlamydia +C. pneumonia3$sittacosis haemo$hilusin!uence, legionella, $neumo$hilia, rucella clostridium,francisella tularensis, neisseria meningitis, mycoacterium

+tuerculosis, salmonella, sta$hylococcus, stre$tococcus A,S" $neumonia, tularemia, tetanus, sy$hilis, Vibrio cholera

S$irocheta% Borrelia recurrentis, le$tos$ira, Treponema pallidum

Rec.ettsia% Coxiella burnetii, R. rickettsii3 prowazekii

5rotozoa% Entamoeba histolytica, leishmania, Plasmodiumfalciparum,Trypanosoma cruzi, Trypanosomabrucei, Toxoplasma ondii

1elmintic% ascaris, Echinococcus ranulosus,Schistosoma, Trichinella spiralis,!uchereria bancrofti



CAUSES Toxic myocarditis has a numer of etiologies

including oth medical agents and en-ironmentalagents"

*umerous medications +eg, lithium,doxoruicin, cocaine, numerouscatecholamines, acetamino$hen

Among the most common drugs that

cause hy$ersensiti-ity reactions are$enicillin, am$icillin,hydrochlorothiazide, methyldo$a, and

sulfonamide drugs"



CA6S0S

0n-ironmental toxins include lead,arsenic, and caron monoxide"

7as$, scor$ion, and s$ider stingsRadiation thera$y may cause amyocarditis 'ith the de-elo$ment of

a dilated cardiomyo$athy"



CAUSES

Immunologic etiologies of myocarditis encom$ass anumer of clinical syndromes and include thefollo'ing%

Connecti-e tissue disorders such assystemic lu$us erythematosus +S80,rheumatoid arthritis, and

dermatomyositis"

Re(ection of the $ost/trans$lant heart may $resentas in!ammatory myocarditis"



Several mechanisms of myocardial damage

(1) Direct injury of myocytes by the infectiousagent

(2) yocyte injury caused by a to!in such asthat from Corynebacterium diphtheriae

(") yocyte injury as a result of infection# induced immune reaction or autoimmunity



Pathophysiology

Tri$hasic disease $rocess

Acute Phase: Characterized by direct infiltration of cardiotropic virusinto myocytes. There is no histological evidence of myocarditis at this point.

Subacute Phase: Host attempts to clear the virus. Natural iller cells!"acrophages! and #ymphoctes infiltrate infected heart tissue. Thee issubse$uent proginflammatory cyto%ine release! N& production!antibody secretion! and upregulation of "HCChronic "yocarditis: 'ilated heart (ith evidence of fibrrosis

$hase I% &iral Infection and 'eplication

$hase 2% utoimmunity and injury

$hase "% Dilated ardiomyopathy



Histopathological image of vial myoca!itis ata"topsy in a patient #ith ac"te onset of congestive

heat fail"e$ %ial etiology& ho#eve& faile! to 'e

!etemine! in postmotem seological st"!y$



Symptoms an! SignsPatients(9) fe*"ently pesent !ays to #ee+s afte an ac"te

fe'ile illness& patic"laly a fl",li+e syn!ome

-yoca!itis is most commonly asymptomatic& #ith no evi!enceof left ventic"la !ysf"nction, feve& malaise& fatig"e& athalgias& myalgias& an! s+in ash$

,Ca!iac symptoms may es"lt fom systolic o !iastolic leftventic"la !ysf"nction o fom tachyahythmias o

'a!yahythmias (!yspnea& fatig"e& !ecease! e.ecisetoleance& palpitations )



Symptoms an! Signs, Chest !iscomfot(/) is a common symptom

an! is typically peica!ial in nat"e

, -yoca!itis may pesent as s"!!en !eath& as a

es"lt of malignant ventic"la ahythmias ocomplete heat 'loc+

, ,Systemic an! p"lmonay thom'oem'oli have

also 'een note!$



Symptoms an! Signs0n cases #hee a !ilate! ca!iomyopathy has

!evelope!& signs of peipheal o p"lmonay

thom'oem'olism may 'e fo"n!$

Diff"se inflammation may !evelop lea!ing to peica!ialeff"sion& #itho"t tampona!e& an! peica!ial an! ple"al

fiction "' as the inflammatoy pocess involves

s"o"n!ing st"ct"es$



linical *indingsPhysical E.amination

,achyca!ia& hypotension& feve an! tachyca!ia may 'e !ispopotionate to the !egee of feve

,2a!yca!ia is seen aely& an! a nao# p"lsepess"e is occasionally !etecte!

,-"m"s of mital o tic"spi! eg"gitation aecommon & S/ an! S3 gallops may also 'e hea!$

,Disten!e! nec+ veins& p"lmonay ales& #hee4es& gallops& an! peipheal e!ema may 'e !etecte!



Diagnostic St"!iesElectoca!iogaphy

,he most common a'nomality is sin"s tachyca!ia$

, may sho# ventic"la ahythmias o heat 'loc+& o itmay mimic the fin!ings in ac"te myoca!ial infaction opeica!itis #ith S segment elevation& S segment!epession& P5 segment !epession& an! pathological6,#aves

,5elations 'et#een these clinical an! la'oatoyfin!ings



Diagnostic St"!iesEchoca!iogaphy , to e.cl"!e othe ca"ses of heat fail"e an!

i!entify ventic"la thom'i$

hee ae no specific echoca!iogaphic feat"es of

myoca!itis$

Segmental o glo'al #all motion a'nomalities can mimic

myoca!ial infaction$

Patients #ith f"lminant myoca!itis ten! to pesent #ith moe

nomal ca!iac cham'e !imensions an! thic+ene! #alls&compae! #ith patients #ith less ac"te myoca!itis #ho have

geate left ventic"la !ilation an! nomal #all thic+ness$

5ight ventic"la !ysf"nction is an "ncommon '"t impotant

pe!icto of !eath o ca!iac tansplantation$



IMA9I*9 ST6DI0SChest a!iogaphy

-50 is capa'le of sho#ing a'nomal signal intensity

in the affecte! myoca!i"m$



Ca!iac cathetei4ation

,elevate! left ventic"la en!,!iastolicpess"e& a !epesse! ca!iac o"tp"t& an!incease! ventic"la vol"mes

,Coonay angiogam typically !emonstates

nomal coonay ateies$



En!omyoca!ial 'iopsy

, gol! stan!a! fo the !iagnosis of myoca!itis ,Dallas citeia (an inflammatoy infiltate of the

myoca!i"m in"y to the a!acent myocytes)

,'o!eline myoca!itis is ma!e #hen theinfiltate is not accompanie! 'y myocyte in"y



omal -yoca!i"m



2o!eline -yoca!itis



Active -yoca!itis



8A)ORATORY ST6DI0S

Ca!iac toponin 0 may 'e moe sensitive 'eca"se it is

pesent fo longe peio!s afte myoca!ial !amage fom

any ca"se$

Eythocyte se!imentation ate (ES5) is elevate! in :;of patients #ith ac"te myoca!itis$

<e"+ocytosis is pesent in = of cases$



OT10R T0STS0f a systemic !iso!e (eg& S<E) is s"specte!&

antin"clea anti'o!y (AA) an! othe collagen

vasc"la !iso!e la'oatoy investigations may 'e

"sef"l$



P5E%E0>Pevention of infectio"s !iseases 'y means of

appopiate imm"ni4ations an! ealy teatment appeas

to 'e impotant in !eceasing the inci!ence of

myoca!itis$



-ED0CA< -AA?E-E*SAIDs such as as$irin and iu$rofen should

not e used during the acute $hase or if heart

failure de-elo$s ecause these can causefurther myocardial damage"

A-oid eta/loc.ers 'hen heart failure ordysrhythmia de-elo$s ecause they decreasethe strength of -entricular contraction"



E%A<UA0>

0x$ected $atient outcomes may include%

:" Relie-ed of $ain

;" Returns to normal acti-ities of daily li-ing

<" Asence of com$lications

=" Increased .no'ledge on his disease

>" Ale to do self/care



References1einz/5eter Schultheiss:,;?, 6'e @uhl:,;, and

8eslie T" Coo$er:,Charite 1os$ital, )erlin,9ermany e"al"The management of

myocarditis "Banuary ;::Ad-ances in the understanding of myocarditis"

Circulation ;::=%:EF"

Geldman AM, Mc*amara D% Myocarditis" * 0ngl B Med ;:H%:<"

Diagnosis and $resentation of fatal myocarditis1uman 5athology +;> <F, :<J :E

Myocarditis 3

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