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

  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]

• 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]

  An approach used only with a patient's consent, this procedure may also confirm acute myocarditis, allowing close monitoring of potential congestive heart failure. [medical-dictionary.thefreedictionary.com]

  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]

• Fatigue

  […] 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 (26 %), fatigue [ncbi.nlm.nih.gov]

  The main symptoms are headache, jaw claudication, polymyalgia rheumatica, visual loss, fatigue, and fever. Pericarditis and myocardial infarction due to coronary arteritis have been rarely reported 1, 2, 3. [jrheum.org]

  Symptoms of myocarditis may start as fatigue, shortness of breath, fever and aching of the joints, all characteristic of a flu-like illness. [medical-dictionary.thefreedictionary.com]

  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]

  Signs and symptoms include chest pain, fatigue, shortness of breath, and arrhythmias. Severe myocarditis weakens your heart so that the rest of your body doesn't get enough blood. Clots can form in your heart, leading to a stroke or heart attack. [mayoclinic.org]

• 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]

  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]

• 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]

  […] symptoms Physical signs Features of viral illness Myalgia, sore throat, diarrhoea, vomiting Fever, tachycardia Myopericarditis Chest pain, breathlessness Pericardial rub, signs of tamponade Myocardial dysfunction Chest pain, breathlessness, collapse, orthopnea [rcemlearning.co.uk]

• 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]

• Chest Pain

  KEYWORDS: Acute myocarditis; Cardiovascular magnetic resonance; Chest pain; Pediatrics [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]

• Heart Disease

  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]

  It may also disguise itself as ischemic, valvular, or hypertensive heart disease. [medical-dictionary.thefreedictionary.com]

• Gallop Rhythm

  A gallop rhythm, produced by the third or fourth heart sound is best heard at the apex. [jpma.org.pk]

  rhythm, raised JVP, pulmonary oedema, low blood pressure and cardiogenic shock Arrhythmias Palpitations, breathlessness, syncope Abnormal pulse rate, rhythm, signs of cardiac failure Jump to: Top Introduction Clinical assessment Differential Diagnosis [rcemlearning.co.uk]

  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]

• 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]

  Possible abnormalities on CXR (see Image): Normal Pulmonary oedema Cardiomegaly Pleural or pericardial effusions CXR showing acute pulmonary oedema (iii) Echocardiography Transthoracic echocardiography is currently recommended in the initial evaluation [rcemlearning.co.uk]

  Diagnostic Modalities The chest x-ray typically demonstrates cardiomegaly and increased pulmonary vascular markings, indicating pulmonary oedema. [jpma.org.pk]

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]

  ST-abnormalities were defined as significant ST-segment elevation and/or significant ST-segment depression and/or T-wave inversion [ 7 ]. [kjim.org]

• 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]

  This third phase of the disease, the chronic phase, is characterised by myocardial fibrosis and development of DCM. 1 This involves chamber dilation and ventricular wall thinning with impairment of the contractile function of the heart, leading to permanent [jpma.org.pk]

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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.
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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.