Myocarditis:

1. Epidemiology 2. Etiology and Pathogenesis 3. Clinical Manifestation 4. Treatment 5. Prognosis

Epidemiology:
Acco nts for 2!" of s dden cardiac deaths in ad lts less than 4! years of age

#ncidence: At a topsy$ 1%&" of asymptomatic patients had e'idence of myocarditis

Pre'alence: + to 15"$ ) t ,-./# reported that 0idiopathic dilated cardiomyopathy is )elie'ed fre1 ently to )e a se1 ela of 'iral myocarditis$ and the distinction )et(een the t(o conditions is often o)sc red in clinical st dies.0 A'erage age of patients (ith myocarditis is 42 years$ ) t yo ng patients are more prone to more se'ere illness Male to *emale ratio is 1.5 : 1

Manolio TA$ /a ghman 2.$ 3odeheffer 3$ et al: Pre'alence and etiology of idiopathic dilated cardiomyopathy 4s mmary of a ,ational -eart$ . ng$ and /lood #nstit te (or5shop6. Am 7 Cardiol 1++28 9+:145:.

Etiology

Myocarditis is defined as inflammation of heart muscles resulting from any etiology ranging from infections, allergens, medications, and trauma.

Most Common Causus of Myocarditis: Northern American and Europe: Adeno, Echo, and Coxsackie Virus. 1 est of the !orld: "rypanosoma Cru#i $Changas %isease& and Coryne'acterium %iptheriae $%iphtheria&. (

1. )atra et al. Acute Myocarditis. Current *pinions in +ediatrics (,,1, 1-:(-./(-. (. 0a1eldar et al. %iptheritic myocarditis: clinical and la'oratory parameters of prognosis and fatal outcome. Annals of tropical paediatrics (,,,, (,:(,2/(13

Table 3. Causes of Myocarditis Infectious: Viral: Adeno1irus, Coxsackie1irus, Cytomegalo1irus, %engue Virus, Echo1irus, Epstein/)arr 1irus, 0epatitis A and C 1irus, 0erpes 4implex Virus, 0epres 5oster 1irus, 06V, 6nfluen#a, Measels, Mumps, +olio 1irus, +ar1o1irus, u'ella, u'eola. )acteria: Actinomyces, )rucella, Clostridium, Coryne'acterium, 7onococcus, 0aemophilus 6nfluen#ae, 8egionella, Meningococcus, Myco'acterium, Myocoplasma pneumoniae, 4almonella, 4higella, 4erratia, 4taphylococcus, 4treptococcus pneumoniae. 4pirochetes: "reponema pallidum, )orrelia 'urgdorferi $8yme %isease&, 8eptospira 9ungi: Aspergillus, )lastomyces, Candida, Coccidioides, Cryptococcus, 0istoplasma, Mucormycoses, Norcardia, 4porothrix 0elminths: "richinosis, 4chistosomiasis Non-Infectious: Medications: Amphetamines, Chemotherapy drgs $Anthracyclines, Cyclophosphamide, 9luorouracil, 68/(, "rastu#uma'&, Cocaine, 8ithium Collegn Vascular %isease: 4arcoidosis, 4cleroderma, 4ystemic lupus erythematosus, !egenera, Churg/4trauss. Allergens: Aceta#olamide, Amitriptyline, Cefaclor, Colchicine, 9urosemide, 6sonia#id, 8idocaine, Methyldopa, +enicilli n, +henyl'uta#one, +henytoin, eserpine, 4treptomycin, "etnaus toxoid, "etracycline, "hia#ides 0ea1y metals: Copper, 6ron, 8ead, Miscellaneous: Car'on monoxided, Cardio1ersion $electrical shock&, 0yperpyrexia, 0ydrocar'ons, 0ypothermia, adiation, Ethanol.

Pathogenesis

Acute +hase: Characteri#ed 'y direct infiltration of cardiotropic 1irus into myocytes. "here is no histological e1idence of myocarditis at this point.

4u'acute +hase: 0ost attempts to clear the 1irus. Natural :iller cells, Macrophages, and 8ymphoctes infiltrate infected heart tissue. "hee is su'se;uent proginflammatory cytokine release, N* production, anti'ody secretion, and upregulation of M0C.

Chronic Myocarditis: %ilated heart <ith e1idence of fi'rrosis.

Pathogenesis

8ie'erman E) et al. Clinicopathologic description of myocaditis. =ournal of American College of Cardiology 1>:1?1@, 1221

Pathogenesis

Acute

4u'acute

Chronic

Auto/6mmune theory: Autoanti'odies against heat mitochondria, adenine nucleotide receptor, muscarinic receptor, myosin hea1y chain, and laminin.

:no<lton :A. "he immune system in 1iral myocarditis: maintaining the 'alance. Circulation esearch 1222B >3:332/?1 Maisch et al. %emonstration of organ specific anti'odies against heart mitochondria $anti/M@& in sera from patients <ith heart disease. Clinical 6mmunology 12>.B 3>:(>(/2(

Clinical Manifestation
4ymptoms: %*E, *rthopnea, Edema, +alpitations, Chest pains $from pericardial inflammation&, 9e1er, 9atigue. +ossi'le flu/like symptoms t<o <eeks prior.

4igns:

*n physical exam: C 4-, =V%, 0epato/Dugular reflux, Ascites E Edema, Crackles. EC7: Atrial fi' E flutter, 8 or 1entricular enlargement, 4inus "achycardia, +VC, V tach, Conduction a'normalities $)))&, 4" ele1ation. CF : Cardiothoracic ratio is usually normal. +ulmonary edema may result from ele1ated filling pressures. )lood !ork: Ele1ated Cardiac En#ymes. Autoanti'odies. Non/in1asi1e tests: Echo, nuclear scans, M 6.

Matsouka 0, 0amada M, 0onda ", et al: E1aluation of acute myocarditis and pericarditis 'y 7d/%"+A enhanced magnetic resonance imaging. Eur 0eart = 13:(>-, 122.

Grainger & Allison's Diagnostic Radiology A Te!tboo" of Medical I#aging$ %t& ed.

Kumar, Robbins, and Cotran: Pathologic Basis of Disease, 7th ed

"reatment: 4upporti1e Care

Acute: 6notropes, 6ntra/aortic 'alloon pump, 8VA%, trans1enous pacemaker *nce clinically sta'le: o1er<helming e1idence for use of ACEi, %iuretics, )eta/)lockers. %igoxin: leads to increased release of inflammatory cytokins and increased mortality.
1

6mmunosuppression: Anless myocarditis is due to 7iant Cell, :a<asakiGs, or systemic autoimmune disease $48E, 4cleroderma, 4arcoidosis&, immunosupressi1e therapy <ith steroids, cyclosporine, or immunoglo'ulins has no impro1ement on sur1i1al. (

1. (.

9eldman et al. Myocarditis. NEM= Vol -.- No 12. 1->>/1-2@ Mason et al. A clinical trial of immunosuppressi1e therapy for myocarditis. NE=M 1223B ---:(?2/@3

+rognosis

McCarthy et al. 8ong/term outcome of fulminant myocarditis as compared <ith acute $nonfulminant& myocarditis. N Engl J Med (,,,B -.(:?2,.

+rognosis

CK-MB patte rn over tim e 35 3! CK-M oglobin 25 2! 15 1! 5 ! 22% A g 23% A g 24% 25% A g A g 29% A g 2&% A g 2:% 2+% A g A g

CK pattern over tim e 9!! 5!! Creatinine Kinase !roponin ! 4!! 3!! 2!! 1!! ! 22% 23% 24% 25% 29% 2&% 2:% 2+% A g A g A g A g A g A g A g A g 5 4.5 4 3.5 3 2.5 2 1.5 1 !.5 !

!roponin ! patte rn over tim e

22% 23% 24% 25% 29% 2&% 2:% 2+% A g A g A g A g A g A g A g A g