Acute viral myocarditis
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Transcript of Acute viral myocarditis
Acute Viral
MyocarditisProf. Dr. Saad S al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital ,Sharjah ,UAE
Myocarditis
Myocarditis is an inflammatory disease of
the cardiac muscle caused by myocardial
infiltration of immunocompetent cells
following any kind of cardiac injury
2/3/2015Acute myocarditis Prof. Dr. Saad S Al Ani Khorfakkan Hospital 2
http://eurheartj.oxfordjournals.org
Acute myocarditis
Is often a result of a viral infection that produces
myocardial necrosis and triggers an immune
response to eliminate the infectious agent
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 3
Causes
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 4
Viral Infections are the most common
etiology though myocardial toxins ,drug
exposures ,hypersensitivity reactions ,and
immune disorders
Causes (cont.)
Coxsackievirus and other enteroviruses,
adenovirus, parvovirus, Epstein-Barr virus, and
cytomegalovirus are the most common causative
agents in children
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RNA viruses
Picornaviruses
Togaviruses
FlavivirusesParamyxoviruses
Orthomyxovirus
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Coxsackie A + BEchovirus
PoliovirusHepatitis virus
Influenza
Respiratory Syncitial virus
Mumps
Rubella
Dengue Fever
Yellow Fever
DNA viruses
Adenovirus
Retrovirus
Herpesviruses
Erythrovirus
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 7
A 1, 2 ,3, and 5
1 (B19V) and 2
Human herpes virus 6 A/B
Cytomegalovirus
HIV
Epstein-Barr virusVaricella-zoster virus
EpidemiologyManifestations are age dependent:
• In infants
viral myocarditis can be fulminant
• In children
acute, myopericarditis with congestive heart
failure
• In older children and adolescents
acute or chronic congestive heart failure.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 8
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 9
http://eurheartj.oxfordjournals.org
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 10
http://eurheartj.oxfordjournals.org
Clinical Manifestations
Sudden death
Acute cardiogenic shock
Asymptomatic or nonspecific generalized illness
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 11
• Children with myocarditis present with
symptoms that can be mistaken for other types
of illnesses; respiratory presentations were
most common.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 12
Clinical Manifestations (cont.)
Infants and young children
Fulminant presentation
Fever, Respiratory distress, Tachycardia,Hypotension, Gallop rhythm, and Cardiacmurmur
Associated findings may include a rash orevidence of end organ involvement such ashepatitis or aseptic meningitis
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 13
Clinical Manifestations (cont.)
Patients with acute or chronic myocarditis
Presentation:
Chest discomfort, Fever, Palpitations, Easyfatigability, or Syncope/Near syncope
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 14
Clinical Manifestations (cont.)
Cardiac findings
Overactive precordial impulse, Galloprhythm, and Apical systolic murmur ofmitral insufficiency
In patients with associated pericardialdisease, a rub may be noted
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 15
Clinical Manifestations (cont.)
Patient with decompensated congestive heart failure
-Hepatic enlargement
-Peripheral edema
-Pulmonary findings such as wheezes orrales
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Diagnosis• Electrocardiographic changes
1. Are nonspecific
2. May include:
i. Sinus tachycardia
ii. Atrial or ventricular arrhythmias
iii. Heart block
iv. Diminished QRS voltages
v. Nonspecific ST and T-wave changes often suggestive of acute ischemia.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 17
Diagnosis (cont.)
• Chest roentgenograms
In severe, symptomatic cases reveal:
1. Cardiomegaly
2. Pulmonary vascular prominence
3. Overt pulmonary edema
4. Pleural effusions.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 18
Diagnosis(cont.)
• Echocardiography
Often shows:
1. Diminished ventricular systolic function
2. Cardiac chamber enlargement
3. Mitral insufficiency
4. Pericardial infusion (occasionally)
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Diagnosis(cont.)
• Endomyocardial biopsy
May be useful in identifying inflammatory
cell infiltrates or myocyte damage
• Molecular viral analysis using polymerase
chain reaction (PCR) techniques.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 20
Diagnosis(cont.)
• Catheterization and biopsy
Should be performed in:
i. Patients suspected to have myocarditis
ii. If there is strong suspicion for unusual
forms of cardiomyopathy such as storage
diseases or mitochondrial defects
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 21
Diagnosis(cont.)
• Supportive but nonspecific tests include
1. Sedimentation rate
2. CPK isoenzymes
3. Cardiac troponin I
4. Brain natriuretic peptide (BNP) levels
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 22
Differential diagnosis
* Carnitine deficiency
* Other metabolic disorders of energy generation
*Hereditary mitochondrial defects
*Idiopathic dilated cardiomyopathy
*Pericarditis
*Anomalies of the coronary arteries
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 23
Management• Primary therapy for acute myocarditis is
supportive
• Acutely, the use of inotropic agents, preferably
milrinone, should be entertained but used with
caution because of their pro-arrhythmic
potential.
• Diuretics are often required as well.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 24
Management (cont.)
• In extremis, mechanical ventilatory supportand mechanical circulatory support with:
*Ventricular assist device implantation or
*ECMO
May be needed to:
*Stabilize the patient’s hemodynamic status
*Act as a bridge to recovery or cardiac
transplantation.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 25
Management (cont.)
• In patients with compensated congestive heart
failure in the outpatient setting:
* Diuretics
*Angiotensin-converting enzyme inhibitors
*Angiotensin receptor blockers
are of use but may be contraindicated in those
presenting with fulminant heart failure and
cardiovascular collapse.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 26
Management (cont.)
Significant atrial or ventricular arrhythmias:
• Specific antiarrhythmic agents ( amiodarone)
should be administered and ICD placement
considered.
• Immunomodulation is controversial.
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 27
Management (cont.)
• Intravenous immune globulin may have a role
in the treatment of acute or fulminant
myocarditis
• Corticosteroids ?
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 28
Management (cont.)
• Relapse has been noted in patients receiving
immunosuppression
• Specific antiviral therapies ?
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 29
Prognosis • In newborns with symptomatic acute
myocarditis is poor, and 75% mortality
• In children and adolescents is better
• Persistent evidence of dilated cardiomyopathy
→ need for cardiac transplantation.
• Recovery of ventricular function has been
reported in 10-50% of patients
2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 30
References
• Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. Sep
2008;29(17):2073-82.
• Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs.
2002;4(3):171-81
• Renko M, Leskinen M, Kontiokari T, et al. Cardiac troponin-I as a screening tool for
myocarditis in children hospitalized for viral infection. Acta Paediatr. Nov 4 2009
• Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric
myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics.
Dec 2007;120(6):1278-85.
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