Mild cases of myocarditis seldom produce any symptoms. In severe cases, the following symptoms are experienced:

• Pain in the chest
• Onset of arrhythmia
• Feeling of shortness of breath, during activity or even at rest
• Development of fatigue
• Swelling in the legs, arm or ankle due to fluid retention
• Common symptoms of viral infections such as headache, fever, body ache, pain in the joints, diarrhea and or soreness in throat

If children are affected by myocarditis, then the following signs and symptoms are evident:

• Onset of fever and rapid breathing
• Difficulty in breathing
• Development of bluish to grayish color of skin

• Fever

  Spotted fever group of rickettsial infections are emerging in Sri Lanka. We describe a patient with rapidly progressing ARDS and myocarditis secondary to spotted fever caused by Rickettsia conorii. [ncbi.nlm.nih.gov]

  It occurs most frequently in the course of the infectious fevers, especially typhoid fever, diphtheria, and scarlet fever, and the sudden deaths in these cases from heart-failure can be traced in nearly every case to myocarditis. [henriettes-herb.com]

  Patients with myocarditis may present with the following signs and symptoms: Mild symptoms of chest pain (in concurrent pericarditis), fever, sweats, chills, dyspnea In viral myocarditis: Recent history (≤1-2 wk) of flulike symptoms of fevers, arthralgias [emedicine.medscape.com]

• Fatigue

  Of note, she had complained of fatigue, feeling constitutionally unwell and a generalised rash in the days prior to her presentation. Her echocardiogram showed normal wall motion and preserved ejection fraction. [ncbi.nlm.nih.gov]

  In more severe cases of the illness, other symptoms may also be present: Chest pain Arrhythmia (fast or irregular heart beat) Shortness of breath upon exertion or even at rest Retention of fluids and swelling in the legs Fatigue Diagnosis After filling [icm-mhi.org]

  Adult patients are commonly asymptomatic or present with nonspecific symptoms, including fever, fatigue, and weakness. [amboss.com]

  Some children may have very few, difficult to detect symptoms, however as myocarditis affects the heart’s ability to pump blood normally, symptoms can include trouble breathing, heart palpitations, chest pain, fatigue and fainting. [nicklauschildrens.org]

• Malaise

  It is a rare but potentially life-threatening disease.We report the case of an 11-year-old girl without medical history who developed an acute malaise and chills, followed by severe shortness of breath and a cardiopulmonary arrest 1 hour after an intramuscular [ncbi.nlm.nih.gov]

  Clinical presentation is variable in severity, ranging from asymptomatic to cardiogenic shock, but it typically is associated with other viral symptoms, including fever and malaise. [radiopaedia.org]

• Ankle Swelling

  The symptoms of heart failure from myocarditis include shortness of breath, fatigue and ankle swelling. The cause is an inflammation of the heart muscle, most often following a viral infection. [rarediseases.org]

• Hodgkin Lymphoma

  Cancers of the lymphatic system are called "lymphomas". The most well known lymphoma is Hodgkin's disease. All the other lymphomas are called non-Hodgkin's lymphoma. CTCL is a sub-type of non-Hodgkin's lymphoma. [aocd.org]

  See Drugs Approved for Non-Hodgkin Lymphoma for more information. (Mycosis fungoides and Sézary syndrome are types of non-Hodgkin lymphoma.) [cancer.gov]

• Cough

  We describe a male patient who presents 2 years posttransplant with cough and dyspnea. A negative pulmonary workup led to an endomyocardial biopsy and the diagnosis of cytomegalovirus (CMV) myocarditis. [ncbi.nlm.nih.gov]

  This is an 27 y/o male who complains of 1 week of progressive DOE, fatigue, dry cough and subjective fevers. No chest pain. Vitals: 74/34 110 99.4 92% RA. Chest X-ray read per radiology: bilateral pneumonia. Post navigation [web.archive.org]

  Skip to content learn bedside ultrasound, one week at a time This is an 27 y/o male who complains of 1 week of progressive DOE, fatigue, dry cough and subjective fevers. No chest pain. Vitals: 74/34 110 99.4 92% RA. [ultrasoundoftheweek.com]

  Pneumonia often comes on suddenly, causing fever, chills, cough, and pus coughed up from the respiratory tract. Continued Pulmonary embolism. [m.webmd.com]

  Often the person has no preceding symptoms of a cold, cough, nasal congestion or rash and only becomes aware of the infection when heart failure occurs. [health.harvard.edu]

• Exertional Dyspnea

  The clinical presentation can be highly variable as patients can present with chest pain, exertional dyspnea and fatigue, or overtly decompensated heart failure and/or cardiogenic shock. 3-5 The initial ECG can also show variable findings including ST [acc.org]

  Distinct sensations include effort/work, chest tightness, and air hunger (the feeling of not enough oxygen).[1] Dyspnea is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations[2] or light exertion. [en.wikipedia.org]

  Clinical presentations of the disease range from nonspecific systemic symptoms (fever, myalgias, palpitations, or exertional dyspnea) to fulminant hemodynamic collapse and sudden death. [web.archive.org]

• Tachypnea

  Fever, tachycardia, bradycardia, hypotension, tachypnea, respiratory distress, lethargy, gallop, murmur, hepatomegaly, and poor perfusion are physical exam findings that may be present in patients with myocarditis, all of which are non-specific. [ahcmedia.com]

  […] transcribe them (less-used variants are omitted): Group Term Combining forms Preponderance of transcriptions (major dictionaries) good eupnea eu- + -pnea yoop-NEE-ə[12][13][11][14] bad dyspnea dys- + -pnea disp-NEE-ə,[13][14][15] DISP-nee-ə[12][11] fast tachypnea [en.wikipedia.org]

• Heart Failure

  KEYWORDS: Eosinophilic myocarditis; Heart failure; Idiopathic hypereosinophilic syndrome; Sri Lanka; Systemic steroids; Young female [ncbi.nlm.nih.gov]

  Year 2016 payment include evaluation of left ventricular systolic function, 30-day heart failure risk standardization readmission measure, and 30-day heart failure mortality rate. [clinicaladvisor.com]

  Heart sounds - soft S1 or S4 gallop rhythm. Signs of heart failure. Aetiology Infection Viral infection is the most common cause of acute myocarditis [ 2 ]. [patient.info]

• Chest Pain

  Rapid or abnormal heart rhythms (arrhythmias) When to see a doctor Contact your doctor if you have symptoms of myocarditis, particularly chest pain and shortness of breath. [mayoclinic.org]

  Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher [en.wikipedia.org]

• Palpitations

  However, if symptoms don’t go away you may need tests such as: an electrocardiogram (ECG) to check for an abnormal heart rhythm, if you have experienced palpitations a chest X-ray, to check for fluid in or around the heart an echocardiogram (echo), if [bhf.org.uk]

  collapse) Acute myocarditis presents over a longer time period with features of heart failure (can lead to cardiomyopathy) Chronic myocarditides (active and persistent) are rare but may cause chest pain/palpitations without LVD. [dundeemedstudentnotes.wordpress.com]

  If you experience chest pain or palpitations, seek emergency help immediately. An EKG, Chest x-ray, and echocardiogram (ECHO) will be preformed. [chemocare.com]

  Because myocarditis presents with non-specific symptoms including chest pain, dyspnoea, and palpitations, it often mimics more common disorders such as coronary artery disease. [ncbi.nlm.nih.gov]

  Some children may have very few, difficult to detect symptoms, however as myocarditis affects the heart’s ability to pump blood normally, symptoms can include trouble breathing, heart palpitations, chest pain, fatigue and fainting. [nicklauschildrens.org]

• Tachycardia

  The most common abnormality seen in myocarditis is sinus tachycardia with non-specific ST segment and T wave changes. [lifeinthefastlane.com]

  Myocarditis should be suspected in patients with a history of flulike symptoms and new evidence of ECG abnormalities, such as sinus tachycardia or concave ST-segment elevations. [amboss.com]

  Her ESR, Troponin I and Brain natriuretic peptide were elevated with normal CRP and electrocardiogram showed sinus tachycardia with wide spread ST depression. [ncbi.nlm.nih.gov]

  Tachycardias [ edit ] In adults and children over 15, resting heart rate faster than 100 beats per minute is labelled tachycardia. Tachycardia may result in palpitation; however, tachycardia is not necessarily an arrhythmia. [en.wikipedia.org]

• Heart Block

  Arrhythmias, particularly complete heart block, appear to be related to the occurrence of more severe and fatal cases. [ncbi.nlm.nih.gov]

  Myocarditis can also be associated with abnormal heart rhythms including atrial flutter, atrial fibrillation, heart block, and ventricular tachycardia. [mottchildren.org]

  block: right bundle branch block, complete heart block, AV block Rule out myocardial infarction: loss of R wave and pathological Q wave specific to myocardial infarction, not found in myocarditis Pericardial effusion: low voltage (low R-wave with poor [amboss.com]

  Myocarditis can also be associated with abnormal heart rhythms such as atrial flutter, atrial fibrillation, heart block and ventricular tachycardia. [umcvc.org]

• Eczema

  This stage may be very subtle histopathologically and mimic other dermatoses such as eczema or lichenoid dermatoses, as the atypia may be difficult to appreciate. [dermnetnz.org]

  Often, it is misdiagnosed as psoriasis or eczema at first and only recognized after several biopsies. Cancers of the lymphatic system are called "lymphomas". The most well known lymphoma is Hodgkin's disease. [aocd.org]

  These lesions may resemble other skin disorders such as psoriasis, parapsoriasis, lichen planus, or eczema. STAGE II: The second stage is called the plaque or “infiltrating stage.” Bluish red circular or oval plaques develop on affected areas. [rarediseases.org]

• Lethargy

  […] and radiation); previous myocardial damage and exercise Infectious type more common in otherwise healthy younger individuals and can be a cause of unexpected death in this group Presentation Fulminant myocarditis often follows a viral prodrome (fever, lethargy [dundeemedstudentnotes.wordpress.com]

  Poor perfusion and lethargy are again common in these children. Hypotension, lethargy, and poor perfusion are the most common exam findings in children over the age of 6 years. [ahcmedia.com]

  IF YOU OR YOUR CHILD ARE ILL, seek immediate treatment of lethargy/fatigue that is out of proportion with fever or general appearance of illness Cardiac Warning Signs Before/During Activity Gradually increase training intensity/volume (no >10% per week [forelysa.org]

  With chronic inflammation, the symptoms are more often unspecific and the disease presents itself as lethargy, fatigue, loss of appetite, limb pain/aching and a reduction in overall physical well-being. [cardiosecur.com]

The following tests are employed for diagnosing the condition of myocarditis:

• Electrocardiogram: This is a non-invasive test, which measures the electrical activity of the heart. It also helps in detecting abnormal heart rhythms.
• Holter monitor: Some abnormalities noticed in the electrocardiogram, would call for further investigation. A holter monitor is a device that records the heart rhythm round the clock and helps in arriving at appropriate diagnosis.
• Imaging studies such as X-ray of the chest and MRI of the heart are carried out. Such tests would reveal inflammation of the muscles of the heart and help in appropriate diagnosis [8].
• Echocardiogram is indicated which would help reveal heart enlargement, poor pumping of the heart and valve problems if any.
• Blood tests: Blood tests to measure the levels of white and red blood cells would be done. An elevated level would suggest infection as the causative factor.
• Biopsy and cardiac catheterization: These are done to check for presence of inflammation of the myocardium [9]. 

• Chlamydia

  […] meningitides Arbovirus Staphylococcus aureus Cytomegalovirus Mycoplasma pneumoniae HIV Salmonella typhi Hepatitis Mycobacterium tuberculosis Epstein-Barr virus Borrelia burgdorferi Mumps Rickettsia rickettsii Poliomyelitis Campylobacter jejuni Herpes simplex Chlamydia [accessmedicine.mhmedical.com]

  Risk Factors for Myocarditis These include: 1) Viral infections: Coxsackie, Influenza, Rubella, Polio, Adeno and HIV have all been implicated. 2) Bacterial infections with agents such as Corynebacterium, Rickettsia, Chlamydia and Coxiella. 3) Protozoal [healthengine.com.au]

  All of the other 12 nucleic acid tests were negative, including influenza A virus, adenovirus, bocavirus, rhinovirus, influenza A (H1N1) 2009, parainfluenza, chlamydia, partial pulmonary virus, influenza B virus, mycoplasma pneumoniae, influenza A virus [acc.org]

  Some of the viruses that can cause myocarditis include: Coxsackie Herpes HIV Hepatitis C Parovirus Mononucelosis Measles Bacteria that can cause myocarditis include: Chlamydia Streptococcus Staphylococcus Fungi that can cause myocarditis include: Candida [wexnermedical.osu.edu]

  Some things that can cause myocarditis include: Coxsackie B viruses Epstein-Barr virus (EBV) Cytomegalovirus (CMV) Hepatitis C Herpes HIV Parvovirus Chlamydia (a common sexually transmitted disease) Mycoplasma (bacteria that cause a lung infection) Streptococcal [webmd.com]

In several cases, myocarditis can resolve without treatment promoting complete recovery. However, many cases may demand an appropriate treatment plan which would primarily focus on correcting the underlying condition. The various treatment methods that are employed include [10]:

• Medications such as antibiotics to treat bacterial infections and anti-inflammatory agents to lessen the swelling in the legs and ankles are prescribed. In addition, digoxin and diuretics to remove excess water from the body in order to reduce the swelling caused due to fluid retention are also administered .
• Ventricular assist device or intra-aortic ballon pump is indicated in severe cases.
• Heart transplantation is usually the last resort and employed when there is severe damage to the heart.

Individuals who can successfully survive fulminant myocarditis usually have a favorable prognosis. It was observed that majority of the patients do well even without a transplant. The onset of left ventricular dysfunction is less severe in individuals with fulminant myocarditis. Individuals with mild symptoms, completely recover with no cardiac dysfunction [6]. However, in patients suffering from giant cell myocarditis, 89% of them did not survive or had to undergo transplantation with median survival period of just 5.5 months after transplant [7].

Viral infections are the most common cause of myocarditis. The various pathogens that are known include parvovirus B19, coxsackievirus B, Epstein-Barr virus, adenovirus and echoviruses. Individuals with HIV/AIDS are also susceptible to develop the condition. In certain cases, bacterial and fungal agents can also cause myocarditis [2].

Underlying disease conditions such as inflammatory conditions, systemic lupus erythematosus and connective tissue diseases can also favor the development of myocarditis. In addition, certain medications such as antibiotics like penicillin, anti-seizure medications and illegal drugs can cause certain toxic reactions which can lead to inflammatory reactions in the myocardium of the heart.

The exact incidence of myocarditis is not known. From the available data, it has been estimated that the condition causes about 1 to 10 cases per 100,000 individuals. The median age of onset of the disease is about 42 years. It has also been estimated that, 5 to 20% of sudden death among young adults occurred due to onset of myocarditis. About 50% of individuals with HIV develop myocarditis as a secondary complication [3] [4].

The condition of myocarditis occurs due to response to an infection which causes the middle layers of the heart muscles to undergo inflammation. Such a type of disease can also strike healthy individuals and it may rapidly progress to arrhythmia and heart failure. Myocarditis can further be classified into the following 4 categories which include:

• Fulminant myocarditis primarily occurs due to viral infection causing ventricular dysfunction. The condition can either resolve spontaneously or it can even turn fatal.
• Acute myocarditis also causes ventricular dysfunction, which progresses to dilated cardiomyopathy.
• Chronic active myocarditis is characterized by ventricular dysfunction accompanied by chronic inflammatory changes.
• Chronic persistent myocarditis, wherein there is no ventricular dysfunction but persistent histologic infiltrate [5].

The following steps can to certain extent help in preventing the onset of myocarditis:

• Promptly treating all type of viral infections and preventing contact with those suffering from the same until they have completely recovered.
• Following good personal hygiene can help in preventing infections.
• Getting regular immunization shots would also go a long way in prevention against the types of viruses that may cause myocarditis.

Myocarditis is also referred to as inflammatory cardiomyopathy. It may present with mild symptoms that resolve on their own seldom requiring treatment. However, in many cases it can also cause severe symptoms and devastating complications. This may occur when the pumping action of the heart weakens to such an extent that it is no longer capable of pumping blood to the rest of the body. In addition, clots can also develop which would in turn pave way for development of heart attack or stroke [1].

• Definition: Myocarditis is inflammation of the myocardium of the heart. It is mostly caused due to viral infections that cause the muscles of the heart to undergo inflammation.
• Cause: Most commonly, viral infections are the major cause. In addition, allergic reactions to certain antibiotics, anti-seizure drugs or illegal drugs can also cause development of myocarditis.
• Symptoms: Symptoms of myocarditis include difficulty in breathing, shortness of breath at rest and during physical activity, chest pain, fatigue, fever, headache and body ache.
• Diagnosis: Myocarditis is diagnosed using electrocardiogram, holter monitor and imaging studies such as X-ray and MRI. In addition to these methods, blood tests, cardiac catheterization, biopsy and echocardiogram are also indicated.
• Treatment: Antibiotics form the preliminary basis of treatment regime if bacterial infections are the source of myocarditis. In addition, medications such as ACE inhibitors, beta blockers, diuretics are also administered for relieving the symptoms and correcting the underlying disease condition. Heart transplantation may also be required if there is severe damage to the heart muscles.

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3. Pulerwitz TC, Cappola TP, Felker GM, et al. Mortality in primary and secondary myocarditis. Am Heart J. Apr 2004;147(4):746-50.
4. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004; 141:829.
5. Miklozek CL, Crumpacker CS, Royal HD, et al. Myocarditis presenting as acute myocardial infarction. Am Heart J 1988; 115:768.
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10. Fuse K, Kodama M, Okura Y, Ito M, Hirono S, Kato K, et al. Predictors of disease course in patients with acute myocarditis. Circulation. Dec 5 2000;102(23):2829-35.