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Myocarditis

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Myocarditis

Uploaded by

venkat sreenath
Copyright
© © All Rights Reserved
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Download as PPTX, PDF, TXT or read online on Scribd
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Myocarditis

Myocarditis – etiology, clinical features and management (Nov ’13) (Apr


’17) DDs and management of myocarditis in infant (May ’01)
Pathology

🠶 The principal mechanism of cardiac involvement in viral myocarditis is believed to be


a cell-mediated immunologic reaction, not merely myocardial damage from viral
replication. Isolation of virus from the myocardium is unusual at autopsy.

🠶 The inflamed myocardium is soft, flabby, and pale, with areas of scarring on gross
examination.

Microscopic examination reveals

🠶 patchy infiltrations by plasma cells, mononuclear leukocytes, and

🠶 some eosinophils during the acute phase and

🠶 giant cell infiltration in the later stages


Cause
🠶 Viruses are probably the most common causes of myocarditis.

🠶 Adenovirus, coxsackievirus B, and echoviruses are the most common agents.

🠶 Many other viruses (e.g., poliomyelitis, mumps, measles, rubella, cytomegalovirus


[CMV], HIV, arboviruses, influenza) can cause myocarditis.

🠶 Chagas’ disease (caused by Trypanosoma cruzi, a protozoan) is a common cause

🠶 Rarely, bacteria, rickettsia, fungi, protozoa, and parasites are the causative agents.

🠶 Immune-mediated diseases, including acute rheumatic fever and Kawasaki’s disease,

🠶 Collagen vascular diseases can cause myocarditis.

🠶 Toxic myocarditis (from drug ingestion, diphtheria exotoxin


Clinical Manifestations
HISTORY
🠶 Older children may have a history of an upper respiratory infection.
🠶 illness may have a sudden onset in newborns and small infants, with anorexia, vomiting,
lethargy, and occasionally circulatory shock.

PHYSICAL EXAMINATION
🠶 Presentation depends on the patient’s age and the acute or chronic nature of the infection.
🠶 In neonates and infants, signs of CHF may be present; these include poor heart tone,
tachycardia, gallop rhythm, tachypnea, and (rarely) cyanosis. In older children, a gradual
onset of CHF and arrhythmia are commonly seen.
🠶 A soft, systolic heart murmur and irregular rhythm caused by supraventricular or ventricular
ectopic beats may be audible.
🠶 Hepatomegaly (evidence of viral hepatitis) may be present.
DIAGNOSIS
CXR :Radiography: Cardiomegaly of varying degrees is the most important clinical sign of
myocarditis
Electrocardiography
🠶 low QRS voltages, ST-T changes,
🠶 PR prolongation, prolongation of the QT interval, and
🠶 arrhythmias (especially premature contractions).
Echocardiography
🠶 Echocardiography reveals cardiac chamber enlargement and
🠶 impaired left ventricle (LV) function, often regional in nature.
🠶 Occasionally, increased wall thickness and LV thrombi are found.
Laboratory Studies:Cardiac troponin levels (troponin I and T) and myocardial enzymes (creatine
kinase [CK], MB isoenzyme of CK [CK-MB]) may be elevated. In children, the normal value of
cardiac troponin I has been reported to be 2 ng/mL or less, and it is frequently below the level of
detection for the assay. Troponin levels may be more sensitive than the cardiac enzymes.
Radionuclide scanning (after administration of gallium-67 or technetium-99m pyrophosphate) may
identify inflammatory and necrotic changes characteristic of myocarditis.
Endomyocardial biopsy. Myocarditis can be confirmed
Natural History
🠶 Mortality rate is as high as 75% in symptomatic neonates with acute viral
myocarditis.

🠶 Majority of patients, especially those with mild inflammation, recover completely.

🠶 Some patients develop subacute or chronic myocarditis with persistent cardiomegaly (with
or without signs of CHF) and ECG evidence of left ventricular hypertrophy (LVH) or
biventricular hypertrophy (BVH). Clinically, these patients are indistinguishable from those
with dilated cardiomyopathy.

🠶 Myocarditis may be a precursor to idiopathic dilated cardiomyopathy in some cases


Management
🠶 Attempt virus identification by viral cultures from the blood, stool, or throat washing.
🠶 Bed rest and limitation in activities are recommended during the acute phase
🠶 Anticongestive measures include the following:
a. Rapid-acting diuretics (furosemide or ethacrynic acid, 1 mg/kg, each one to three times a day)
b. Rapid-acting inotropic agents, such as dobutamine or dopamine, are useful in critically ill children.
c. Oxygen and bed rest are recommended. Use of a “cardiac chair” or “infant seat” relieves respiratory distress.
d. Digoxin may be given cautiously using half of the usual digitalizing dose
🠶 Recently, beneficial effects of high-dose gamma globulin (2 g/kg over 24 hours) have been reported. Gamma
globulin was associated with better survival during the first year after presentation, echocardiographic evidence of
smaller LV diastolic dimension, and higher fractional shortening compared with the control group.
🠶 Myocardial damage in myocarditis is mediated in part by immunologic mechanisms, and a high dose of
gamma globulin is an immunomodulatory agent, shown to be effective in myocarditis secondary to Kawasaki’s
disease.
🠶 Angiotensin-converting enzyme inhibitors, such as captopril, may prove beneficial in the acute phase
🠶 Arrhythmias should be treated aggressively and may require the use of IV amiodarone.
🠶 The role of corticosteroids is unclear at this time except in the treatment of severe rheumatic carditis.
🠶 Specific therapies include antitoxin in diphtheritic myocarditis.

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