Myocarditis: Difference between revisions
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== Background == | == Background == | ||
*Inflammatory cardiomyopathy (dilated cardiomyopathy) caused by necrosis of myocytes from infectious agents, their toxins, and cytotoxic effects of activated host immunity | *Inflammatory cardiomyopathy (dilated cardiomyopathy) caused by necrosis of myocytes from infectious agents, their toxins, and cytotoxic effects of activated host immunity | ||
*Majority caused by enterovirus (Cocksackie B) and adenovirus. Also influenza A/B, Hep B, B Hemolytic Streptococcus, Mycoplasma, Mumps, CMV and Toxoplasma (cardiac transplant), Chagas (leading cause worldwide) Trichinosis, Diphtheria, Lyme | *Majority caused by enterovirus (Cocksackie B) and adenovirus. Also influenza A/B, Hep B, B Hemolytic Streptococcus, Mycoplasma, Mumps, CMV and Toxoplasma (cardiac transplant), Chagas (leading cause worldwide) Trichinosis, Diphtheria, Lyme | ||
*Drugs: Doxorubicin, Cocaine | *Drugs: Doxorubicin, Cocaine | ||
===Phases=== | |||
*Acute: Viral cytotoxicity and focal necrosis | |||
*Subacute: Host's humoral/immune response leading to further cell injury | |||
*Chronic: Diffuse myocardial fibrosis and cardiac dysfunction | |||
== Clinical Features == | == Clinical Features == | ||
*Typically young/few risk factors for CAD | *Typically young/few risk factors for CAD | ||
*Chest | *[[Chest pain]] | ||
*No sensitive symptom or sign but can have flu like syndrome: fever, fatigue, myalgia, N/V; tachycardia (out of proportion to fever), tachypnea, new onset CHF | *No sensitive symptom or sign but can have flu like syndrome: fever, fatigue, myalgia, N/V; tachycardia (out of proportion to fever), tachypnea, new onset CHF | ||
*In Peds: grunting, retractions, ronchi. Infants may have fulminant syndrome: Fever, cyanosis, respiratory distress, tachycardia, cardiac failure, ventricular dysrhythmias | *In Peds: grunting, retractions, ronchi. Infants may have fulminant syndrome: Fever, cyanosis, respiratory distress, tachycardia, cardiac failure, ventricular dysrhythmias | ||
*May have pericardial friction rub | *May have pericardial friction rub | ||
*Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids. | *Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids. | ||
== Differential Diagnosis == | |||
*Acute [[MI]] | |||
*[[Pericarditis ]] | |||
*[[CHF]] | |||
== Diagnosis == | == Diagnosis == | ||
*[[ECG]]: Sinus tach, low voltages, prolonged QTc, AV block, Acute MI pattern (Usually >1 vessel distribution) | |||
*ECG: Sinus tach, low voltages, prolonged QTc, AV block, Acute MI pattern (Usually >1 vessel distribution) | |||
*TropI: Elevated | *TropI: Elevated | ||
*Echo: Decreased LVEF, global hypokinesis, regional wall motion abnormalities | *Echo: Decreased LVEF, global hypokinesis, regional wall motion abnormalities | ||
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*Viral titers | *Viral titers | ||
*Endocardial biopsy: Gold standard | *Endocardial biopsy: Gold standard | ||
== Treatment == | == Treatment == | ||
*Acute Phase: Antiviral agents may be effective with replicating virus: Pleconaril/Ribavirin | *Acute Phase: Antiviral agents may be effective with replicating virus: Pleconaril/Ribavirin | ||
*Subacute: Studies have not shown efficacy of immunosupressants. Peds: High dose IVIG | *Subacute: Studies have not shown efficacy of immunosupressants. Peds: High dose IVIG | ||
*Chronic: Treat CHF symptoms, Ventricular Assist Devices (VAD), cardiac transplant | *Chronic: Treat CHF symptoms, Ventricular Assist Devices (VAD), cardiac transplant | ||
== | == Disposition == | ||
*If [[CHF]]: Admit to monitored bed; ICU for hemodynamic instability | |||
*If CHF: Admit to monitored bed; ICU for hemodynamic instability | |||
*Fulminant myocarditis has best prognosis | *Fulminant myocarditis has best prognosis | ||
*Mortality: 20% 1 yr/ 50% 5 yr | *Mortality: 20% 1 yr/ 50% 5 yr | ||
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== See Also == | == See Also == | ||
*[[Cardiomyopathy]] | |||
*[[Pericarditis]] | |||
== References == | |||
== | |||
[[Category:Cards]] | [[Category:Cards]] | ||
Revision as of 11:55, 29 June 2015
Background
- Inflammatory cardiomyopathy (dilated cardiomyopathy) caused by necrosis of myocytes from infectious agents, their toxins, and cytotoxic effects of activated host immunity
- Majority caused by enterovirus (Cocksackie B) and adenovirus. Also influenza A/B, Hep B, B Hemolytic Streptococcus, Mycoplasma, Mumps, CMV and Toxoplasma (cardiac transplant), Chagas (leading cause worldwide) Trichinosis, Diphtheria, Lyme
- Drugs: Doxorubicin, Cocaine
Phases
- Acute: Viral cytotoxicity and focal necrosis
- Subacute: Host's humoral/immune response leading to further cell injury
- Chronic: Diffuse myocardial fibrosis and cardiac dysfunction
Clinical Features
- Typically young/few risk factors for CAD
- Chest pain
- No sensitive symptom or sign but can have flu like syndrome: fever, fatigue, myalgia, N/V; tachycardia (out of proportion to fever), tachypnea, new onset CHF
- In Peds: grunting, retractions, ronchi. Infants may have fulminant syndrome: Fever, cyanosis, respiratory distress, tachycardia, cardiac failure, ventricular dysrhythmias
- May have pericardial friction rub
- Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids.
Differential Diagnosis
- Acute MI
- Pericarditis
- CHF
Diagnosis
- ECG: Sinus tach, low voltages, prolonged QTc, AV block, Acute MI pattern (Usually >1 vessel distribution)
- TropI: Elevated
- Echo: Decreased LVEF, global hypokinesis, regional wall motion abnormalities
- Contrast MR
- Nuclear Study: Widespread uptake indicating myocyte necrosis
- Viral titers
- Endocardial biopsy: Gold standard
Treatment
- Acute Phase: Antiviral agents may be effective with replicating virus: Pleconaril/Ribavirin
- Subacute: Studies have not shown efficacy of immunosupressants. Peds: High dose IVIG
- Chronic: Treat CHF symptoms, Ventricular Assist Devices (VAD), cardiac transplant
Disposition
- If CHF: Admit to monitored bed; ICU for hemodynamic instability
- Fulminant myocarditis has best prognosis
- Mortality: 20% 1 yr/ 50% 5 yr
- Children with 70% survival rateat 5 yrs
- Complications
- Vent. Dysrhythmias
- LV anneurysm
- CHF