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MYOCARDITISMyocarditis is collection of diseases of
infectious, toxic, and autoimmune etiologiescharacterized y in!ammation of the heart"
Suse#uent myocardial destruction can leadto dilated cardiomyo$athy"
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Dallas Classification (1987) Initial BiopsyMyocarditis% Myocardial necrosis, degeneration, or oth,
in the asence of signi&cant coronary artery disease 'ithad(acent in!ammatory in<rate 'ith or 'ithout &rosis"
)orderline myocarditis% In!ammatory in<rate too s$arseor myocyte damage not a$$arent"
*o myocarditis
Subsequent Biopsies
Ongoing +$ersistent myocarditis 'ith or 'ithout &rosis"Resol-ing +healing myocarditis 'ith or 'ithout &rosis"
Resol-ed +healed myocarditis 'ith or 'ithout &rosis"
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CAUSESAmongst the infectious causes, -iral acute
myocarditis is y far the most common"
Identi&cation of the coxsac.ie/adeno-irus
Other -iruses im$licated in myocarditisinclude in!uenza -irus, echo-irus,her$es sim$lex -irus, -aricella/zoster
-irus, he$atitis, 0$stein/)arr -irus, andcytomegalo-irus"
1uman immunode&ciency -irus +1I2
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CAUSES*on-iral infectious causes are numerous and -aried"
)acteria% chlamydia +C. pneumonia3$sittacosis haemo$hilusin!uence, legionella, $neumo$hilia, rucella clostridium,francisella tularensis, neisseria meningitis, mycoacterium
+tuerculosis, salmonella, sta$hylococcus, stre$tococcus A,S" $neumonia, tularemia, tetanus, sy$hilis, Vibrio cholera
S$irocheta% Borrelia recurrentis, le$tos$ira, Treponema pallidum
Rec.ettsia% Coxiella burnetii, R. rickettsii3 prowazekii
5rotozoa% Entamoeba histolytica, leishmania, Plasmodiumfalciparum,Trypanosoma cruzi, Trypanosomabrucei, Toxoplasma ondii
1elmintic% ascaris, Echinococcus ranulosus,Schistosoma, Trichinella spiralis,!uchereria bancrofti
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CAUSES Toxic myocarditis has a numer of etiologies
including oth medical agents and en-ironmentalagents"
*umerous medications +eg, lithium,doxoruicin, cocaine, numerouscatecholamines, acetamino$hen
Among the most common drugs that
cause hy$ersensiti-ity reactions are$enicillin, am$icillin,hydrochlorothiazide, methyldo$a, and
sulfonamide drugs"
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CA6S0S
0n-ironmental toxins include lead,arsenic, and caron monoxide"
7as$, scor$ion, and s$ider stingsRadiation thera$y may cause amyocarditis 'ith the de-elo$ment of
a dilated cardiomyo$athy"
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CAUSES
Immunologic etiologies of myocarditis encom$ass anumer of clinical syndromes and include thefollo'ing%
Connecti-e tissue disorders such assystemic lu$us erythematosus +S80,rheumatoid arthritis, and
dermatomyositis"
Re(ection of the $ost/trans$lant heart may $resentas in!ammatory myocarditis"
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Several mechanisms of myocardial damage
(1) Direct injury of myocytes by the infectiousagent
(2) yocyte injury caused by a to!in such asthat from Corynebacterium diphtheriae
(") yocyte injury as a result of infection# induced immune reaction or autoimmunity
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Pathophysiology
Tri$hasic disease $rocess
Acute Phase: Characterized by direct infiltration of cardiotropic virusinto myocytes. There is no histological evidence of myocarditis at this point.
Subacute Phase: Host attempts to clear the virus. Natural iller cells!"acrophages! and #ymphoctes infiltrate infected heart tissue. Thee issubse$uent proginflammatory cyto%ine release! N& production!antibody secretion! and upregulation of "HCChronic "yocarditis: 'ilated heart (ith evidence of fibrrosis
$hase I% &iral Infection and 'eplication
$hase 2% utoimmunity and injury
$hase "% Dilated ardiomyopathy
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Histopathological image of vial myoca!itis ata"topsy in a patient #ith ac"te onset of congestive
heat fail"e$ %ial etiology& ho#eve& faile! to 'e
!etemine! in postmotem seological st"!y$
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Symptoms an! SignsPatients(9) fe*"ently pesent !ays to #ee+s afte an ac"te
fe'ile illness& patic"laly a fl",li+e syn!ome
-yoca!itis is most commonly asymptomatic& #ith no evi!enceof left ventic"la !ysf"nction, feve& malaise& fatig"e& athalgias& myalgias& an! s+in ash$
,Ca!iac symptoms may es"lt fom systolic o !iastolic leftventic"la !ysf"nction o fom tachyahythmias o
'a!yahythmias (!yspnea& fatig"e& !ecease! e.ecisetoleance& palpitations )
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Symptoms an! Signs, Chest !iscomfot(/) is a common symptom
an! is typically peica!ial in nat"e
, -yoca!itis may pesent as s"!!en !eath& as a
es"lt of malignant ventic"la ahythmias ocomplete heat 'loc+
, ,Systemic an! p"lmonay thom'oem'oli have
also 'een note!$
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Symptoms an! Signs0n cases #hee a !ilate! ca!iomyopathy has
!evelope!& signs of peipheal o p"lmonay
thom'oem'olism may 'e fo"n!$
Diff"se inflammation may !evelop lea!ing to peica!ialeff"sion& #itho"t tampona!e& an! peica!ial an! ple"al
fiction "' as the inflammatoy pocess involves
s"o"n!ing st"ct"es$
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linical *indingsPhysical E.amination
,achyca!ia& hypotension& feve an! tachyca!ia may 'e !ispopotionate to the !egee of feve
,2a!yca!ia is seen aely& an! a nao# p"lsepess"e is occasionally !etecte!
,-"m"s of mital o tic"spi! eg"gitation aecommon & S/ an! S3 gallops may also 'e hea!$
,Disten!e! nec+ veins& p"lmonay ales& #hee4es& gallops& an! peipheal e!ema may 'e !etecte!
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Diagnostic St"!iesElectoca!iogaphy
,he most common a'nomality is sin"s tachyca!ia$
, may sho# ventic"la ahythmias o heat 'loc+& o itmay mimic the fin!ings in ac"te myoca!ial infaction opeica!itis #ith S segment elevation& S segment!epession& P5 segment !epession& an! pathological6,#aves
,5elations 'et#een these clinical an! la'oatoyfin!ings
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Diagnostic St"!iesEchoca!iogaphy , to e.cl"!e othe ca"ses of heat fail"e an!
i!entify ventic"la thom'i$
hee ae no specific echoca!iogaphic feat"es of
myoca!itis$
Segmental o glo'al #all motion a'nomalities can mimic
myoca!ial infaction$
Patients #ith f"lminant myoca!itis ten! to pesent #ith moe
nomal ca!iac cham'e !imensions an! thic+ene! #alls&compae! #ith patients #ith less ac"te myoca!itis #ho have
geate left ventic"la !ilation an! nomal #all thic+ness$
5ight ventic"la !ysf"nction is an "ncommon '"t impotant
pe!icto of !eath o ca!iac tansplantation$
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IMA9I*9 ST6DI0SChest a!iogaphy
-50 is capa'le of sho#ing a'nomal signal intensity
in the affecte! myoca!i"m$
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Ca!iac cathetei4ation
,elevate! left ventic"la en!,!iastolicpess"e& a !epesse! ca!iac o"tp"t& an!incease! ventic"la vol"mes
,Coonay angiogam typically !emonstates
nomal coonay ateies$
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En!omyoca!ial 'iopsy
, gol! stan!a! fo the !iagnosis of myoca!itis ,Dallas citeia (an inflammatoy infiltate of the
myoca!i"m in"y to the a!acent myocytes)
,'o!eline myoca!itis is ma!e #hen theinfiltate is not accompanie! 'y myocyte in"y
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omal -yoca!i"m
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2o!eline -yoca!itis
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Active -yoca!itis
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8A)ORATORY ST6DI0S
Ca!iac toponin 0 may 'e moe sensitive 'eca"se it is
pesent fo longe peio!s afte myoca!ial !amage fom
any ca"se$
Eythocyte se!imentation ate (ES5) is elevate! in :;of patients #ith ac"te myoca!itis$
<e"+ocytosis is pesent in = of cases$
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OT10R T0STS0f a systemic !iso!e (eg& S<E) is s"specte!&
antin"clea anti'o!y (AA) an! othe collagen
vasc"la !iso!e la'oatoy investigations may 'e
"sef"l$
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P5E%E0>Pevention of infectio"s !iseases 'y means of
appopiate imm"ni4ations an! ealy teatment appeas
to 'e impotant in !eceasing the inci!ence of
myoca!itis$
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-ED0CA< -AA?E-E*SAIDs such as as$irin and iu$rofen should
not e used during the acute $hase or if heart
failure de-elo$s ecause these can causefurther myocardial damage"
A-oid eta/loc.ers 'hen heart failure ordysrhythmia de-elo$s ecause they decreasethe strength of -entricular contraction"
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E%A<UA0>
0x$ected $atient outcomes may include%
:" Relie-ed of $ain
;" Returns to normal acti-ities of daily li-ing
<" Asence of com$lications
=" Increased .no'ledge on his disease
>" Ale to do self/care
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References1einz/5eter Schultheiss:,;?, 6'e @uhl:,;, and
8eslie T" Coo$er:,Charite 1os$ital, )erlin,9ermany e"al"The management of
myocarditis "Banuary ;::Ad-ances in the understanding of myocarditis"
Circulation ;::=%:EF"
Geldman AM, Mc*amara D% Myocarditis" * 0ngl B Med ;:H%:<"
Diagnosis and $resentation of fatal myocarditis1uman 5athology +;> <F, :<J :E
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