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Acute Myocarditis

Acute myocarditis is a potentially life-threatening inflammatory disorder of the myocardium, most commonly caused by viral pathogens such as coxsackie A and B, as well as influenza viruses and other enteroviruses, but an array of infections and autoimmune etiologies have been described. Chest pain, dyspnea, and syncope are principal symptoms. The clinical course, however, varies from asymptomatic to sudden cardiac death. A comprehensive clinical workup comprised of laboratory, imaging, and microbiological studies are necessary to make the diagnosis.


Presentation

Acute myocarditis (AM) is defined as an inflammatory disease involving the myocardium and its exact pathogenesis model remains to be completely elucidated [1] [2] [3] [4]. AM can arise on the grounds of various infections and autoimmune disorders [1] [2] [3] [4]. By far, viruses are responsible for the majority of cases, primarily enteroviruses (coxsackie A or B and echoviruses), but also Epstein-Barr virus (EBV), hepatitis C virus (HCV), and increasingly important human herpesvirus 6 (HHV6) and parvovirus B19, which were recently identified as the main causes of myocarditis in Germany [1] [5] [6]. In addition, bacteria (Brucella spp., Clostridium spp., Francisella spp., Legionella, etc.), fungal microorganisms (Aspergillus, Candida, Cryptococcus, Histoplasma), and a number of parasites have been reported as a cause of myocarditis as well [1] [4]. On the other hand, sarcoidosis, Wegener's granulomatosis, celiac disease, connective tissue disorders, rheumatic fever, but also various drugs (antimicrobials, diuretics, antipsychotics, etc.) are notable non-infectious etiologies of myocarditis [1] [4]. The clinical presentation starts with a flu-like symptomatology (fatigue, malaise, and constitutional symptoms), followed by dyspnea, palpitations, arrhythmias, and chest pain with discomfort as the main symptoms [1] [7]. However, patients may be completely asymptomatic or develop severe cardiac insufficiency that results in heart failure and sudden death, and up to 9% of all sudden cardiac deaths have been attributed to myocarditis in certain reports [4] [7] [8]. Tachycardia, cardiogenic shock, and a syndrome mimicking myocardial infarction (MI) or coronary heart disease (CAD) can be seen in severe cases [1] [2]. Although the short-term prognosis of acute myocarditis is generally good [7], long-term sequelae in the form of cardiomyopathy and progressive decline in cardiac functions are observed [3] [4], thus illustrating the importance of an early diagnosis and proper treatment.

Fever
  • He had a history of a cold with a fever of 39 C occurring three days earlier. Electrocardiography (ECG) showed complete atrioventricular block (AV block) with a maximum pause of 32 seconds, for which temporary pacing was performed.[ncbi.nlm.nih.gov]
  • On the other hand, sarcoidosis, Wegener's granulomatosis, celiac disease, connective tissue disorders, rheumatic fever, but also various drugs (antimicrobials, diuretics, antipsychotics, etc.) are notable non-infectious etiologies of myocarditis.[symptoma.com]
  • We report a case of dengue hemorrhagic fever (DHF) complicated by acute myocarditis and review the literature. A 65-year-old woman experienced DHF due to dengue virus serotype 3, complicated with acute myocarditis and acute pulmonary edema.[ncbi.nlm.nih.gov]
  • Japanese spotted fever (JSF) is caused by Rickettsia japonica. Although it induces a variety of complications, acute myocarditis has never been reported as a complication of JSF. We treated a JSF patient who developed acute myocarditis.[ncbi.nlm.nih.gov]
  • Three days before his death, the patient developed fever. On the day of death, he described an urge to defecate and attempted to do so in an upright position.[ncbi.nlm.nih.gov]
Congestive Heart Failure
  • We reported the case of a 12-year-old girl with congestive heart failure, acute myocarditis and pericardial effusion as a primary manifestation of SLE.[ncbi.nlm.nih.gov]
  • A 60-year-old man presented with pneumonia and congestive heart failure. On the first day of admission, he was found to have an elevated troponin-l level and severe global left ventricular systolic dysfunction on echo-cardiography.[ncbi.nlm.nih.gov]
  • heart failure at presentation.[heart.bmj.com]
  • Fulminant myocarditis is a distinct entity characterized by sudden onset of severe congestive heart failure or cardiogenic shock, usually following a flu-like illness.[journals.lww.com]
  • The rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n 5) ( Figure 4 ).[cdt.amegroups.com]
Malaise
  • A 43-year-old previously healthy Taiwanese male came to our emergency department due to high fever, chills, general malaise and myalgia for about 4 days. An influenza rapid test from a throat swab was negative.[ncbi.nlm.nih.gov]
  • The clinical presentation starts with a flu-like symptomatology (fatigue, malaise, and constitutional symptoms), followed by dyspnea, palpitations, arrhythmias, and chest pain with discomfort as the main symptoms.[symptoma.com]
  • The clinical indications to perform CMR were chest pain and/or dyspnea and/or palpitations, or effort intolerance/malaise in the last month; elevated troponin and/or new ventricular dysfunction, and/or new ECG abnormalities; and suspected inflammatory[ncbi.nlm.nih.gov]
  • They may complain of a flu-like illness with of fatigue, malaise and fever. They may not be able to tolerate exercise or may complain of chest pain or palpitations (skipped or extra heartbeats). They may develop a cough.[cincinnatichildrens.org]
  • METHODS Our patient, was a male, 38 years old, Caucasian, coming from another hospital, reporting a picture 6 weeks before of mononucleosis like syndrome with enlargement of neck lynphonodes, malaise, and fever, that lasted for few days and improved with[scielo.br]
Dyspnea
  • The clinical presentation was an influenzae-like syndrome, classical for a CMV infection, without any chest pain or dyspnea, but a systematic exploration showed multiple inflammation-compatible myopericardial images on MNR-scan.[ncbi.nlm.nih.gov]
  • The patient was a 50-year-old woman who had been under medication for acute myocarditis when she complained of sudden severe dyspnea. Echocardiography showed a mobile snake-like thrombus in the RA.[ncbi.nlm.nih.gov]
  • Chest pain, dyspnea, and syncope are principal symptoms. The clinical course, however, varies from asymptomatic to sudden cardiac death.[symptoma.com]
  • Case 1: A 48-years-old, previously healthy male patient admitted to our clinic with complaints of acute onset of rest dyspnea and orthopnea, started the day before.[ncbi.nlm.nih.gov]
  • The CMR protocol comprised cine sequences, T2-weighted edema imaging and late gadolinium enhancement (LGE) imaging on a 1.5-T MR scanner. 89 patients (28 7 years, 89 % male) were included to this study presenting with symptoms of chest pain (85 %), dyspnea[ncbi.nlm.nih.gov]
Rales
  • The arterial pressure was 89x56 and MAP of 67 mmHg, there was a gallop rhythm with rales in both lung fields. There was intense vasoconstriction with absence of pulses down to the popliteal arteries.[scielo.br]
  • Physical exam will look like congestive heart failure, with jugular venous distention, pulmonary rales, peripheral edema, pulsatile liver, and perhaps a laterally displaced point of maximal impulse (PMI). E.[clinicaladvisor.com]
Orthopnea
  • Case 1: A 48-years-old, previously healthy male patient admitted to our clinic with complaints of acute onset of rest dyspnea and orthopnea, started the day before.[ncbi.nlm.nih.gov]
Sputum
Chest Pain
  • Myocarditis should be considered in all patients presenting with acute onset chest pain and elevated cardiac biomarkers.[ncbi.nlm.nih.gov]
  • KEYWORDS: Acute myocarditis; Cardiovascular magnetic resonance; Chest pain; Pediatrics[ncbi.nlm.nih.gov]
  • Coronary vasospasm is one cause of chest pain in patients with acute myocarditis. This is a rare association, with few cases reported in the literature.[ncbi.nlm.nih.gov]
  • The clinical presentation was an influenzae-like syndrome, classical for a CMV infection, without any chest pain or dyspnea, but a systematic exploration showed multiple inflammation-compatible myopericardial images on MNR-scan.[ncbi.nlm.nih.gov]
  • A man aged 25 years was admitted with chest pain, dizziness, headache, palpitations and sweating. His troponin was mildly positive.[ncbi.nlm.nih.gov]
Tachycardia
  • Monoamine oxidase inhibitors (MAOIs) are uncommonly used due to their high frequency of adverse effects, including tachycardia and hypertension.[ncbi.nlm.nih.gov]
  • We describe an unusual case of a 44-year-old woman who was hospitalized for ventricular tachycardia, deep asthenia and dyspnoea with no previous history of cardiac disease.[ncbi.nlm.nih.gov]
  • The main presenting complaint observed was irritability (73%) and least common symptom was abdominal pain (23%) while the most frequently occurring examination finding was tachycardia (90%).[ncbi.nlm.nih.gov]
  • We describe the case of a young man presenting with acute heart failure, who had electrocardiographic changes suggesting myocardial ischaemia and an episode of sustained ventricular tachycardia.[ncbi.nlm.nih.gov]
  • Sudden cardiovascular collapse due to ventricular fibrillation (VF), ventricular tachycardia (VT) and cardiac tamponade occurred.[ncbi.nlm.nih.gov]
Heart Disease
  • Tachycardia, cardiogenic shock, and a syndrome mimicking myocardial infarction (MI) or coronary heart disease (CAD) can be seen in severe cases.[symptoma.com]
  • Acute viral myocarditis (AVM) is an inflammatory heart disease that may lead to acute heart failure caused by cardiomyocyte loss. AVM may result in fatal outcome due to hemodynamic compromise. There is no specific treatment for AVM.[ncbi.nlm.nih.gov]
  • ., MD, and a panel of leading clinical and scientific experts comprehensively review both advances in basic scientific understanding and current clinical knowledge of inflammatory heart disease.[books.google.com]
  • ICD-10-CM Codes › I00-I99 Diseases of the circulatory system › I30-I52 Other forms of heart disease › Type 1 Excludes Type 1 Excludes Help A type 1 excludes note is a pure excludes. It means "not coded here".[icd10data.com]
  • Home 2012 ICD-9-CM Diagnosis Codes Diseases Of The Circulatory System 390-459 Other Forms Of Heart Disease 420-429 Acute myocarditis 422- 422 Acute myocarditis 422.0 Acute myocarditis in diseases classified elsewhere convert 422.0 to ICD-10-CM 422.9 Other[icd9data.com]
Cardiomegaly
  • […] supraventricular and ventricular arrhythmias can occur in patients with myocarditis The presence of Q waves or a new left bundle branch block (LBBB) are associated with higher rates of cardiac death or heart transplantation Radiology description Chest Xray: cardiomegaly[pathologyoutlines.com]
Gallop Rhythm
  • The arterial pressure was 89x56 and MAP of 67 mmHg, there was a gallop rhythm with rales in both lung fields. There was intense vasoconstriction with absence of pulses down to the popliteal arteries.[scielo.br]

Workup

The life-threatening nature of AM necessitates a thorough diagnostic workup, starting with a detailed patient history that will identify the course and progression of symptoms, recent travel (to exclude certain viral, fungal or parasitic infections), and the presence of comorbidities that may contribute to clinical deterioration. The physical examination is perhaps even more important, which can reveal tachycardia, cardiac murmurs (soft S1 sound, S3 or S4 gallop, as well as sounds pointing toward insufficiency of the mitral or tricuspid valve), a pericardial friction rub, and a displaced punctum maximum [1] [4]. A full body inspection must not be overlooked, as it may lead to findings such as lymphadenopathy, subcutaneous nodules, joint sensitivity (typical for sarcoidosis and rheumatic fever, respectively) or other signs of that might point to the underlying cause [4]. As soon as the heart is identified as the source of symptoms, cardiac enzymes: troponin I, troponin T, and creatine kinase-MB (CK-MB) must be evaluated to exclude myocardial infarction, after which electrocardiography (EKG) and imaging studies, primarily cardiac ultrasonography, should be employed [1]. Although clear diagnostic criteria do not exist for acute myocarditis, an overall reduced activity of the myocardium (hypokinesia) is the main finding, but more importantly, other etiologies (valvular or congenital heart disease, as well as myocardial infarction) can be ruled out [1] [4]. Extensive microbiological testing is available, mainly through serology and blood cultures, but the introduction of molecular testing (eg. polymerase chain reaction, or PCR) has markedly improved the overall success of identifying microorganisms in patient samples [1]. Endomyocardial biopsy is a definite method for confirmation of AM, but it is indicated only if the procedure is assumed to have a vitally important effect on the therapeutic course [1] [4] [9] [10].

Right Bundle Branch Block
  • It has also been described in a work the report of sequences of alternatively normal and Wenckebach beats with alternate and progressive right bundle branch block interpreted as functional longitudinal dissociation in atrioventricular conduction axis[ncbi.nlm.nih.gov]
T Wave Inversion
  • Abstract BACKGROUND: The pathophysiologic mechanisms and the prognostic meaning of electrocardiographic (ECG) T-wave inversion (TWI) occurring in a subgroup of patients with clinically suspected acute myocarditis remain to be elucidated.[ncbi.nlm.nih.gov]
  • T-wave inversions (negative T-waves) ST elevations are normalized slowly in pericarditis. It may take weeks for the ST elevations to resolve. Thereafter, T-wave inversion typically ensues.[ecgwaves.com]
Myocardial Fibrosis
  • Myocardial fibrosis was assessed in conventional late gadolinium enhancement (LGE) images. A value of 12.1 g of Hyp-DIA was obtained as cut-off of normality in healthy controls.[ncbi.nlm.nih.gov]

Treatment

  • There is no specific treatment for AVM. Treatment is generally same as the treatment of conventional heart failure. Levosimendan is a new molecule with inotropic and vasodilator effect and is widely used for acute decompensated heart failure.[ncbi.nlm.nih.gov]
  • Endomyocardial biopsy may be performed in an individualized basis both for diagnostic purposes and to guide treatment, based on the detection or not of viral genome.[ncbi.nlm.nih.gov]
  • Treatment with metformin also alleviated the histological abnormalities in the heart, suppressed the upregulation of myeloperoxidase (MPO), decreased the elevation of creatinine kinase-myocardial band (CK-MB) and brain natriuretic peptide (BNP).[ncbi.nlm.nih.gov]
  • Percutaneous treatment is useful for treating free-floating RA thrombi.[ncbi.nlm.nih.gov]
  • These findings may be valuable for the diagnosis and treatment of affected patients.[ncbi.nlm.nih.gov]

Prognosis

  • OBJECTIVES: This study sought to evaluate the role of CMR and LGE in the prognosis of AM with preserved LVEF.[ncbi.nlm.nih.gov]
  • Improving short-term and long-term prognosis is challenging but can probably be achieved by new diagnostic techniques and novel targeted therapies.[ncbi.nlm.nih.gov]
  • PURPOSE: To determine the value of cardiac MRI for the monitoring and the prognosis of patients with acute myocarditis. Cardiac MRI plays an increasingly important role in the diagnosis of acute myocarditis.[ncbi.nlm.nih.gov]
  • These findings also hold true when only the viral forms are considered and are different from previous studies showing better prognosis in FM. 2017 American Heart Association, Inc.[ncbi.nlm.nih.gov]
  • BACKGROUND: The long-term prognosis of biopsy-proven myocarditis is not well known. We hypothesized that a detailed pathological examination of an endomyocardial biopsy (EMB) would reveal prognostic information in patients with acute myocarditis.[ncbi.nlm.nih.gov]

Etiology

  • […] myocarditis is a potentially life-threatening inflammatory disorder of the myocardium, most commonly caused by viral pathogens such as coxsackie A and B, as well as influenza viruses and other enteroviruses, but an array of infections and autoimmune etiologies[symptoma.com]
  • It is now considered to be an important etiology of pediatric cardiomyopathy.[ncbi.nlm.nih.gov]
  • A lobar pneumonia caused by Mycoplasma pneumoniae, was radiographically and serologically diagnosed in the first patient (a 15-year-old boy) and a febrile diarrhea of unidentified etiology, despite repetitive stool cultures and serological assessments[ncbi.nlm.nih.gov]
  • The main differential diagnoses with other frequent etiological causes of sudden arrhythmia are: idiopathic outflow tract ventricular tachycardia of the RV, myocarditis, dilated cardiomyopathy and sarcoidosis.[ncbi.nlm.nih.gov]
  • Kawasaki disease, a systemic vasculitis of unknown etiology, develops frequently in infants and demonstrates a variety of clinical symptoms during the disease course.[ncbi.nlm.nih.gov]

Epidemiology

  • CrossRef Google Scholar Volume 14 , Issue 5 October 2004 , pp. 488-493 (a1) Division of Pediatric Cardiology, Department of Pediatrics, University of Florida , Jacksonville, USA (a2) Department of Family Medicine and Clinical Epidemiology, University[cambridge.org]
  • […] was first introduced by Corvisart It is defined by WHO / International Society and Federation of Cardiology (ISFC) as an inflammatory disease of the heart muscle, diagnosed by established histological, immunological and immunohistochemical criteria Epidemiology[pathologyoutlines.com]
  • Giant cell myocarditis, sarcoidosis, Kawasaki disease, Crohn disease, systemic lupus erythematosus, ulcerative colitis, Wegener granulomatosis, thyrotoxicosis, scleroderma, rheumatoid arthritis Peripartum cardiomyopathy Posttransplant cellular rejection Epidemiology[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • The objectives of this review are: (1) to detail the current state of knowledge of the pathophysiological mechanisms of acute myocarditis; (2) to provide an update on diagnostic tools such as magnetic resonance imaging and endomyocardial biopsy; and ([ncbi.nlm.nih.gov]
  • Differences in viral pathophysiology may contribute to differences in outcome. Alternatively, arrhythmia risk may differ by location.[acc.org]
  • The pathophysiology of GCA myocarditis is unknown; diffuse vasculitis of small myocardial vessels has been suspected 4.[jrheum.org]
  • Abstract BACKGROUND: The pathophysiologic mechanisms and the prognostic meaning of electrocardiographic (ECG) T-wave inversion (TWI) occurring in a subgroup of patients with clinically suspected acute myocarditis remain to be elucidated.[ncbi.nlm.nih.gov]
  • […] criteria Epidemiology Postmortem data identify myocarditis in 8.6% to 12% of cases of sudden death in young adults The Myocarditis Treatment Trial reported the incidence of biopsy proven myocarditis in patients with unexplained heart failure to be 9.6% Pathophysiology[pathologyoutlines.com]

Prevention

  • Cardiac 18F-fluorodeoxyglucose/positron emission tomography was used to confirm the resolution of her acute myocarditis and was critical to the decision-making process that prevented unnecessary pacemaker insertion.[ncbi.nlm.nih.gov]
  • To avoid otherwise preventable morbidity and mortality, physicians should have a high index of suspicion for cardiac complications in patients with dengue illness and should manage this accordingly.[ncbi.nlm.nih.gov]
  • A pre-selection of such patients for CMR based on serum cardiac enzymes--but not on ECG recordings--may prevent a meaningless overuse of CMR.[ncbi.nlm.nih.gov]
  • Prevention There's no specific prevention for myocarditis. However, taking these steps to prevent infections might help: Avoid people who have a viral or flu-like illness until they've recovered.[mayoclinic.org]

References

Article

  1. Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. 2008;29(17):2073-2082.
  2. Dec GW, Jr, Waldman H, Southern J, Fallon JT, Hutter AM, Jr, Palacios I. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol. 1992;20:85–89
  3. Shauer A, Gotsman I, Keren A, et al. Acute viral myocarditis: current concepts in diagnosis and treatment. Isr Med Assoc J. 2013;15(3):180-185.
  4. Schultz JC, Hilliard AA, Cooper LT, Rihal CS. Diagnosis and Treatment of Viral Myocarditis. Mayo Clinic Proceedings. 2009;84(11):1001-1009.
  5. Mahrholdt H, Wagner A, Deluigi CC, et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation. 2006;114:1581–1590.
  6. Matsuura H, Ichida F, Saji T, et al. Clinical Features of Acute and Fulminant Myocarditis in Children - 2nd Nationwide Survey by Japanese Society of Pediatric Cardiology and Cardiac Surgery. Circ J. 2016;80(11):2362-2368.
  7. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. Lancet. 2012;379(9817):738-747.
  8. Fabre A, Sheppard MN. Sudden adult death syndrome and other non‐ischaemic causes of sudden cardiac death. Heart. 2006;92(3):316-320.
  9. Hunt SA, Baker DW, Chin MH, et al. Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation. 2001;104:2996–3007
  10. Cooper LT, Baughman KL, Feldman AM, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. Eur Heart J. 2007;28:3076–3093.

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Last updated: 2019-07-11 21:36