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Myocardial Abscess

Abscess of Myocardium

A myocardial abscess is a suppurative infection located in the endocardium or myocardium, that may involve the heart conduction system, valvular apparatus or neighboring structures, most often caused by infective endocarditis or septicemia. This condition is potentially life-threatening, making an early diagnosis and therapy mandatory.


Presentation

In septic conditions, myocardial abscess symptoms may be concealed by signs of infection of other organs. The presence of a myocardial abscess is suggested by clinical deterioration and abnormal heart rhythm in a patient suspected of infectious endocarditis. This latter entity is associated with new or altered heart murmurs [1], acute or aggravated chronic heart failure signs and little or no response to antibiotics. Abrupt development of complete or Mobitz II heart block, conduction defects [2] or severe ventricular arrhythmias strongly suggest a myocardial abscess. This should also be suspected in sepsis along with the development of an acute myocardial infarction or in those with penetrating chest injuries. Most individuals are febrile and have chills and sweats but severely debilitated, chronic kidney disease or elderly individuals may have normal temperature. Additional symptoms include lack of appetite with weight loss, malaise [3], respiratory symptoms like a cough and dyspnea, general findings like as myalgia, arthralgia, confusion, headache or abdominal pain.

Patients are generally tachycardic and exhibit peripheral endocarditis manifestations: Osler nodes, Roth spots, Janeway lesions, petechiae, splenomegaly, clubbing and embolic events, especially neurologic, renal and pulmonary. If the aortic valve is involved, pulse pressure will be wide because of the valvular regurgitation. Catastrophic heart wall rupture, although infrequent, is possible [4], as is the presence of multiple, remote abscesses [5], as opposed to lesions resulting from direct extension from an infected structure, usually valvular [6].

Tender Spleen
  • spleen It is not uncommon for many of these symptoms to be associated with acute viral infections like the seasonal flu.[healthhype.com]
Fever
  • One week after extubation, he suddenly developed fever and disturbance of consciousness. Candida albicans was detected from blood and cerebrospinal fluid culture.[keio.pure.elsevier.com]
  • Fever, chills and signs of pericarditis were the main clinical features. Mild enteritis 1 week prior to the onset of symptoms related to the abscess was the most likely cause of the bacteremia.[ncbi.nlm.nih.gov]
Congestive Heart Failure
  • New to the third edition are: - Expanded coverage of the coronary heart disease syndromes; congestive heart failure; arrhythmias; pacing; sudden death; lipid management (including clinical results), and a completely revised and updated section on noninvasive[books.google.com]
  • Moore PT, Proto AV (1984) Juxtacardiac mass and congestive heart failure. Chest 86(1):95–96 PubMed Google Scholar 10. Escarous A (1989) CT findings of a posterior false aneurysm of the left ventricle (letter).[link.springer.com]
  • Evidence of congestive heart failure. New conduction disturbance. Vascular or immunological phenomena: embolic event, Roth's spots, splinter haemorrhages, Janeway's lesions, Osler's nodes. A new stroke.[patient.info]
  • A S3 gallop indicates left-sided congestive heart failure.[atsu.edu]
  • This may also result in hematogenous seeding and disseminated tuberculosis. 9 Clinically, tuberculomas may be asymptomatic or may present with arrhythmias, 5 complete heart block, 8 , 10 congestive heart failure, 11 superior vena caval obstruction, 12[cmaj.ca]
Malaise
  • Additional symptoms include lack of appetite with weight loss, malaise, respiratory symptoms like a cough and dyspnea, general findings like as myalgia, arthralgia, confusion, headache or abdominal pain.[symptoma.com]
  • Case presentation A 28-year-old intravenous drug user was admitted in a district general hospital with a 2-week history of fever, malaise and myalgia. He had no past medical history of note.[jmedicalcasereports.biomedcentral.com]
  • Other signs and symptoms include the following: Anorexia Weight loss Malaise Dyspnea Cough Stroke Headache Nausea/vomiting Myalgia Arthralgia Chest pain Abdominal pain Back pain Confusion Sweats Physical Physical examination findings commonly encountered[emedicine.medscape.com]
  • […] endocarditis include congenital heart disease, rheumatic heart disease, IV drug use, degenerative valve disease and intracardiac devices. [1], [2] Clinical manifestations of infective endocarditis include high grade fever, chills, sweating, anorexia, malaise[jcecho.org]
  • A protracted history of sweats, weight loss, anorexia or malaise and an at-risk cardiac lesion (see 'Risk factors', above). Any new unexplained embolic event (eg, cerebral or limb ischaemia). Unexplained, persistently positive blood cultures.[patient.info]
Fever of Unknown Origin
  • A 73 year old male was hospitalised with fever of unknown origin and episodes with septic shock. During the in-hospital stay the clinical situation deteriorated rapidly, and E. coli was isolated from bloodcultures.[ncbi.nlm.nih.gov]
Pathologist
  • Kradin is also an Associate Pathologist at Massachusetts General Hospital in the Immunopathology Unit. His techniques include tissue culture and immunocytochemistry, flow cytometry, Northern blotting and immunocytochemistry. Dr.[books.google.com]
Heart Disease
  • The relative incidence of myocardial abscesses occurring in the presence of acute or chronic ischemic heart disease is unknown.[ncbi.nlm.nih.gov]
  • Presents comprehensive coverage of valvular heart disease to provide you with a complete reference and one-stop shop for this specialty in cardiac medicine.[books.google.com]
  • CASE REPORT A 46 year old Italian male barber, with the diagnosis of inactive rheumatic heart disease, had been followed for a long period.[annals.org]
  • Children, especially if suffering from congenital heart diseases, may also develop infective endocarditis and myocardial abscesses, that may be complicated by aneurysm formation.[symptoma.com]
Ejection Murmur
  • There was a systolic ejection murmur (grade 2/6) and a diastolic murmur (grade 4/6) in the aortic area. There was a moderate pain-ful splenomegaly. The lungs were clear and there was no peripheral edema.[romanianjournalcardiology.ro]

Workup

Blood workup in myocardial abscess should include a complete cell blood count, that will highlight the presence of leukocytosis with granulocytosis and inflammatory, normochromic, normocytic anemia. Serum iron level and iron binding capacity are diminished. Low platelet numbers are possible. A complete chemistry panel is useful in order to determine renal and hepatic status at the moment of presentation. Myocardial abscesses are frequently accompanied by azotemia. Inflammatory markers are increased in most patients, with an erythrocyte sedimentation rate of about 55 mm/h. Blood cultures are indispensable and should optimally be obtained before antibiotic therapy is started. Microscopic hematuria and proteinuria are not infrequent.

Chest radiography is only useful in order to assess pulmonary status and cardiac silhouette, which may serve as an indicator for chronic heart failure. Although it has a low sensitivity, a transthoracic echocardiogram is mandatory in order to evaluate heart morphology especially that of the valves, the presence of regurgitations and contractility. A myocardial abscess, although it may not be visible itself, is suggested by the presence of an echo-free space inside the myocardial mass, rocking of prosthetic valves, septum perivalvular density with a diameter that exceeds 14 mm and aneurysmal dilatation of a Valsalva sinus [7]. Real-time 3-dimensional contrast transthoracic echography offers in some cases a reliable description of the pathological process [8], as do transesophageal echocardiography [9], Indium-In 111 leukocyte scintigraphy and magnetic resonance imaging [10]. However, some cases remain undiagnosed until surgery is performed.

The electrocardiogram often offers little information, but in some patients, gradual PR prolongation or new conduction abnormalities have been described. A cardiac catheterization is only employed in cases that are going to be referred for surgery so that coronary artery disease is confirmed or excluded.

Children, especially if suffering from congenital heart diseases, may also develop infective endocarditis and myocardial abscesses [11], that may be complicated by aneurysm formation [12].

Normocytic Anemia
  • Blood workup in myocardial abscess should include a complete cell blood count, that will highlight the presence of leukocytosis with granulocytosis and inflammatory, normochromic, normocytic anemia.[symptoma.com]
Septal Q Wave
  • Two additional findings were noted in the present case: echocardiographic evidence of septal thickening, and loss of septal Q waves on the electrocardiogram.[ncbi.nlm.nih.gov]
Mycobacterium Fortuitum
  • A case of pacemaker infection complicated by bacteremia and myocardial abscess caused by Mycobacterium fortuitum is reported and 9 other cases of pacemaker infection associated with rapidly growing mycobacteria are reviewed.[ncbi.nlm.nih.gov]
  • Myocardial abscess and bacteremia complicating Mycobacterium fortuitum pacemaker infection: case report and review of the literature.[biomedsearch.com]

Treatment

  • In addition to reporting this case, we discuss our diagnostic and treatment considerations. To our knowledge, this is only the 4th report of S. aureus bacterial pancarditis with myocardial abscess.[ncbi.nlm.nih.gov]
  • Holmes Springer Science & Business Media, ٠٦‏/١٢‏/٢٠٠٧ - 2926 من الصفحات Cardiovascular Medicine, 3rd Edition offers the most up-to-date, user-friendly guidance on the evaluation, diagnosis and medical and surgical treatment of heart and vascular disease[books.google.com]
  • The vigorous treatment protocols are available for IE.[drsvenkatesan.com]

Prognosis

  • Whether you are attempting to choose a course of therapy, ascertain the optimal timing for intervention, arrive at a prognosis, or determine the possible need for periodic diagnostic evaluation, this is an essential resource you'll consult time and time[books.google.com]
  • Still the prognosis and outcome with medical management is dismal even in best centers.So the role of surgery in IE has increased over the years.We propose here, a radically different approach to the problem.[drsvenkatesan.com]
  • The prognosis for a myocardial abscess is good if it is detected early and treated promptly.[healthhype.com]
  • Prognosis With early diagnosis and prompt surgical treatment, patients improve rapidly. Without surgical intervention, the prognosis worsens very significantly.[emedicine.medscape.com]
  • […] asymptomatic or may present with arrhythmias, 5 complete heart block, 8 , 10 congestive heart failure, 11 superior vena caval obstruction, 12 right ventricular outflow obstruction, 13 aortic insufficiency 14 and sudden cardiac death. 15 In general, the prognosis[cmaj.ca]

Etiology

  • Only one of these reports describes a myocardial abscess of bacterial etiology secondary to an infected intravascular hemodialysis catheter.[ncbi.nlm.nih.gov]
  • Looking at the images it can ne seen that when cut the lesion has purulent content, so the a bacterial etiology should be considered in the first place. Pyogenic bacteria arriving to the heart though a hematogenous route.[cresa.cat]
  • Authors: Hussam Al Soub; Mona Al Maslamani; Jameela Al Khuwaiter; Yasser El Deeb; Mohammed Abu Khattab Related Documents : 8334559 - Etiologic diagnosis of pulmonary infection by ultrasonically guided percutaneous lung a... 15667489 - Pyogenic liver abscess[biomedsearch.com]
  • However, not uncommonly, these abscesses have a polymicrobial etiology.[emedicine.medscape.com]
  • The primary etiology of the narrowing of LAD and CX was the surrounding inflammation, which compressed the arteries.[romanianjournalcardiology.ro]

Epidemiology

  • Epidemiology Frequency United States Myocardial abscess rarely occurs in the United States.[emedicine.medscape.com]
  • Better understanding of the bacteriologic features, pathogenicity, and epidemiology of the S. milleri group should aid clinicians in recognizing and treating properly with this elusive pathogen.[path.upmc.edu]
  • Epidemiology Forced exercise, pregnancy, use of steroids or nonsteroidal anti-inflammatory agents, use of ethanol, and nutritional deficiencies are factors that predispose a patient to symptomatic myocarditis.[atsu.edu]
  • Epidemiological trends of infective endocarditis: a population-based study in Olmsted County, Minnesota [published correction appears in Mayo Clin Proc. 2010;85(8):772]. Mayo Clin Proc. 2010;85(5):422–426. 18.[aafp.org]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Endocarditis The most common clinical setting for myocardial abscess is as a complication of endocarditis involving either native or prosthetic valves.[emedicine.medscape.com]
  • Pathophysiology The development of infectious endocarditis requires the presence of bacteria or fungi in the blood and an intracardiac surface on which these microorganisms can attach.[aafp.org]
  • 第12回日本心不全学会 最優秀ポスター賞 尾上 健児 「Soluble Fms-like Tyrosine Kinase 1 (sFlt-1), A Candidate Molecule Involved in Pathophysiology of Cardio-Renal Connection」 2. 平成20年度日本腎臓財団公募助成 腎不全病態研究助成 久保 篤史 「胚性幹細胞を用いたエリスロポエチン産生細胞の固定とその産生制御についての検討」 3.[naramed-u.ac.jp]

Prevention

  • Prevention of a Myocardial Abscess Early diagnosis and prompt treatment of infective endocarditis may prevent a myocardial abscess from occurring. The focus should therefore be on preventing infective endocarditis.[healthhype.com]
  • Succinct, targeted coverage of normal childhood growth and development, as well as the diagnosis, management, and prevention of common pediatric diseases and disorders, make this an ideal medical reference book for students, pediatric residents, nurse[books.google.com]
  • Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Available at . JAMA. 1997 Jun 11. 277(22):1794-801. [Medline]. Daniel WG, Nellessen U, Schroeder E.[emedicine.medscape.com]
  • Uncontrolled infection and prevention of embolic phenomena. Large mobile vegetations greater than 10 mm diameter.[jcecho.org]

References

Article

  1. Arnett EN, Roberts WC. Valve ring abscess in active infective endocarditis. Frequency, location, and clues to clinical diagnosis from the study of 95 necropsy patients. Circulation. 1976;54(1):140-5.
  2. Gonzalez Vilchez FJ, Martin Duran R, Delgado Ramis C, et al. Active infective endocarditis complicated by paravalvular abscess. Review of 40 cases. Rev Esp Cardiol. 1991; 44(5):306-12.
  3. Vega Moller D, Eske Bruun N. Substantial Myocardial Abscess in an Immunocompromised Patient: Fatal Outcome After Coagulase-negative Staphylococcal Native Valve Infection. JASE. 2007;20(3):333.e5–333.e8.
  4. Khan B, Strate RW, Hellman R. Myocardial abscess and fatal cardiac arrhythmia in a hemodialysis patient with an arterio-venous fistula infection. Semin Dial. 2007;20(5):452-4.
  5. Shackcloth MJ, Dihmis WC. Contained rupture of a myocardial abscess in the free wall of the left ventricle. Ann Thorac Surg. 2001;72: 617-9.
  6. Anguera I, Quaglio G, Ferrer B, et al. Sudden death in Staphylococcus aureus-associated infective endocarditis due to perforation of a free-wall myocardial abscess. Scand J Infect Dis. 2001;33(8):622–5.
  7. Ellis SG, Goldstein J, Popp RL. Detection of endocarditis-associated perivalvular abscesses by two- dimensional echocardiography. J Am Coll Cardiol. 1985;5(3):647-53.
  8. Walker N, Bhan A, Desai J, et al. Myocardial abscess: a rare complication of valvular endocarditis demonstrated by 3D contrast echocardiography. Eur J Echocardiogr. 2010;11(10): E37.
  9. Hill EE, Herijgers P, Claus P, et al. Abscess in infective endocarditis: The value of transesophageal echocardiography and outcome: A 5-year study. Am H Journ. 2007;154: 923-8.
  10. Reynier C, Garcier J, Legault B, et al. Cross-sectional imaging of post endocarditis paravalvular myocardial abscesses of native mitral valves: 4 cases. J Radiol. 2001;82: 665-9.
  11. Day MD, Gauvreau K, Shulman S, et al. Characteristics of children hospitalized with infective endocarditis. Circulation. 2009;119(6):865-70.
  12. Gaur L, Madan S, Morell V, et al. Formation of ventricular aneurysm after endocarditis in a child with methicillinresistant Staphylococcus aureus (MRSA) bacteremia. Pediatr Cardiol. 2011;32(7):1062-4.

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Last updated: 2019-06-28 11:27