Myocarditis: Difference between revisions
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==Background == | {{Adult top}} [[myocarditis (peds)]] | ||
*Inflammatory | ==Background== | ||
* | *Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes | ||
*Drugs | |||
===Causes=== | |||
*Infectious agents | |||
**[[Enterovirus]] (Coxsackie B) and [[adenovirus]] most common | |||
**[[Influenza]] A and B | |||
**[[Hepatitis B]] | |||
**[[Beta-hemolytic streptococcus]] | |||
**[[Mycoplasma]] | |||
**[[Mumps]] | |||
**[[CMV]] | |||
**[[Toxoplasma]] | |||
**[[Chagas]] (most common cause worldwide) | |||
**[[Trichinosis]] | |||
**[[Diphtheria]] | |||
**[[Lyme disease]] | |||
**[[COVID-19]]<ref>[https://link.springer.com/article/10.1007/s11739-021-02635-w Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w]</ref> | |||
*Drugs | |||
**[[Doxorubicin]] | |||
**[[Cocaine]] | |||
===Phases=== | ===Phases=== | ||
*Acute | *Acute | ||
*Subacute | **Viral cytotoxicity and focal necrosis | ||
*Chronic | *Subacute | ||
**Host's humoral/immune response leading to further cell injury | |||
*Chronic | |||
**Diffuse myocardial fibrosis and cardiac dysfunction | |||
==Clinical Features == | ==Clinical Features== | ||
*Typically young | *Typically young patients (20 - 50 years) with few risk factors for CAD | ||
*[[Chest pain]] | *[[Chest pain]] | ||
* | *Pericardial friction rub | ||
* | *[[Flu-like symptoms]] | ||
**[[Fever]], [[fatigue]], [[myalgia]], [[nausea and vomiting]] | |||
*Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids | **[[Tachycardia]] (out of proportion to fever) | ||
**[[Tachypnea]] | |||
*New onset [[congestive heart failure]] | |||
*Pediatric patients: | |||
**Grunting | |||
**Retractions | |||
**Ronchi | |||
*Infants may have fulminant syndrome | |||
**[[Fever]] | |||
**Cyanosis | |||
**[[Shortness of breath (peds)|Respiratory distress]] | |||
**[[Tachycardia]] | |||
**[[Heart failure]] | |||
**[[Ventricular dysrhythmias]] | |||
*Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
''Consider other causes of [[CHF]]'' | |||
{{Chest Pain DDX}} | |||
==Evaluation== | ==Evaluation== | ||
*[[ECG]] | *[[ECG]] | ||
* | **Sinus [[tachycardia]] | ||
* | **[[low voltage ECG|Low voltages]] | ||
**[[Prolonged QTc]] | |||
**[[AV block]] | |||
**[[ST elevation]]s (Usually >1 vessel distribution) | |||
*Elevated [[troponin]] | |||
*[[Echocardiography]] | |||
**Decreased LVEF | |||
**Global hypokinesis | |||
**Regional wall motion abnormalities | |||
*Contrast MR | *Contrast MR | ||
*Nuclear Study | *Nuclear Study | ||
*Viral | **Widespread uptake indicating myocyte necrosis | ||
*Endocardial biopsy: Gold standard | *Viral titres | ||
*Endocardial biopsy: Gold standard, but rarely used | |||
== | ==Management== | ||
*Acute | *Acute phase | ||
*Subacute | **Antiviral agents (Pleconaril/[[Ribavirin]]) may be effective | ||
*Chronic | **COVID-related: limited/conflicting evidence regarding efficacy of high-dose [[steroids]] and/or [[IVIG]] <ref>[https://link.springer.com/article/10.1007/s11739-021-02635-w Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w]</ref> | ||
*Subacute phase | |||
**Studies have not shown efficacy of immunosupressants | |||
**Pediatric patients may receive high-dose [[IVIG]] | |||
*Chronic phase | |||
**Treatment for CHF symptoms | |||
**Ventricular Assist Devices ([[LVAD|VAD]]) | |||
**Cardiac transplant | |||
==Disposition == | ==Disposition== | ||
*If [[CHF]] | *If [[CHF]] is present, admit to monitored bed | ||
*If hemodynamically unstable, admit to ICU | |||
==Prognosis== | |||
*Fulminant myocarditis has best prognosis | *Fulminant myocarditis has best prognosis | ||
*Mortality: 20% 1 yr/ 50% 5 yr | *Mortality: 20% 1 yr/ 50% 5 yr | ||
*Children with 70% survival | *Children with 70% survival rate at 5 yrs<br> | ||
==Complications== | ==Complications== | ||
*Ventricular dysrhythmias | *[[Ventricular dysrhythmias]] | ||
*LV | *[[LV aneurysm]] | ||
*[[CHF]] | *[[CHF]] | ||
==See Also == | ==See Also== | ||
*[[Cardiomyopathy]] | *[[Cardiomyopathy]] | ||
*[[Pericarditis]] | *[[Pericarditis]] | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Cardiology]] | [[Category:Cardiology]] |
Latest revision as of 19:56, 24 February 2021
This page is for adult patients. For pediatric patients, see: myocarditis (peds)
Background
- Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes
Causes
- Infectious agents
- Enterovirus (Coxsackie B) and adenovirus most common
- Influenza A and B
- Hepatitis B
- Beta-hemolytic streptococcus
- Mycoplasma
- Mumps
- CMV
- Toxoplasma
- Chagas (most common cause worldwide)
- Trichinosis
- Diphtheria
- Lyme disease
- COVID-19[1]
- Drugs
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 patients (20 - 50 years) with few risk factors for CAD
- Chest pain
- Pericardial friction rub
- Flu-like symptoms
- Fever, fatigue, myalgia, nausea and vomiting
- Tachycardia (out of proportion to fever)
- Tachypnea
- New onset congestive heart failure
- Pediatric patients:
- Grunting
- Retractions
- Ronchi
- Infants may have fulminant syndrome
- Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids
Differential Diagnosis
Consider other causes of CHF
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
- ECG
- Sinus tachycardia
- Low voltages
- Prolonged QTc
- AV block
- ST elevations (Usually >1 vessel distribution)
- Elevated troponin
- Echocardiography
- Decreased LVEF
- Global hypokinesis
- Regional wall motion abnormalities
- Contrast MR
- Nuclear Study
- Widespread uptake indicating myocyte necrosis
- Viral titres
- Endocardial biopsy: Gold standard, but rarely used
Management
- Acute phase
- Subacute phase
- Studies have not shown efficacy of immunosupressants
- Pediatric patients may receive high-dose IVIG
- Chronic phase
- Treatment for CHF symptoms
- Ventricular Assist Devices (VAD)
- Cardiac transplant
Disposition
- If CHF is present, admit to monitored bed
- If hemodynamically unstable, admit to ICU
Prognosis
- Fulminant myocarditis has best prognosis
- Mortality: 20% 1 yr/ 50% 5 yr
- Children with 70% survival rate at 5 yrs
Complications
See Also
References
- ↑ Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w
- ↑ Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w