Myocarditis: Difference between revisions

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==Background ==
{{Adult top}} [[myocarditis (peds)]]
*Inflammatory cardiomyopathy (dilated cardiomyopathy) caused by necrosis of myocytes from infectious agents, their toxins, and cytotoxic effects of activated host immunity
==Background==
*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
*Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes  
*Drugs: Doxorubicin, Cocaine
 
===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: Viral cytotoxicity and focal necrosis  
*Acute
*Subacute: Host's humoral/immune response leading to further cell injury  
**Viral cytotoxicity and focal necrosis  
*Chronic: Diffuse myocardial fibrosis and cardiac dysfunction
*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 patients (20 - 50 years) with few risk factors for CAD  
*[[Chest pain]]  
*[[Chest pain]]  
*No sensitive symptom or sign but can have flu like syndrome: fever, fatigue, myalgia, nausea and vomiting; tachycardia (out of proportion to fever), tachypnea, new onset CHF
*Pericardial friction rub
*In Peds: grunting, retractions, ronchi. Infants may have fulminant syndrome: Fever, cyanosis, respiratory distress, tachycardia, cardiac failure, ventricular dysrhythmias  
*[[Flu-like symptoms]]
*May have pericardial friction rub
**[[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==
*Acute [[MI]]
''Consider other causes of [[CHF]]''
*[[Pericarditis ]]
{{Chest Pain DDX}}
*[[CHF]]


==Evaluation==
==Evaluation==
*[[ECG]]: Sinus tachycardia, low voltages, [[prolonged QTc]], AV block, Acute MI pattern (Usually >1 vessel distribution)  
*[[ECG]]
*TropI: Elevated  
**Sinus [[tachycardia]]
*Echo: Decreased LVEF, global hypokinesis, regional wall motion abnormalities  
**[[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: Widespread uptake indicating myocyte necrosis  
*Nuclear Study
*Viral titers
**Widespread uptake indicating myocyte necrosis  
*Endocardial biopsy: Gold standard
*Viral titres
*Endocardial biopsy: Gold standard, but rarely used


==Treatment ==
==Management==
*Acute Phase: Antiviral agents may be effective with replicating virus: Pleconaril/Ribavirin
*Acute phase
*Subacute: Studies have not shown efficacy of immunosupressants. Peds: High dose IVIG  
**Antiviral agents (Pleconaril/[[Ribavirin]]) may be effective
*Chronic: Treat CHF symptoms, Ventricular Assist Devices (VAD), cardiac transplant
**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]]: Admit to monitored bed; ICU for hemodynamic instability
*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 rateat 5 yrs<br>  
*Children with 70% survival rate at 5 yrs<br>


==Complications==
==Complications==
*Ventricular dysrhythmias  
*[[Ventricular dysrhythmias]]
*LV anneurysm
*[[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

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

  • 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

Emergent

Nonemergent

Evaluation

Management

  • Acute phase
    • Antiviral agents (Pleconaril/Ribavirin) may be effective
    • COVID-related: limited/conflicting evidence regarding efficacy of high-dose steroids and/or IVIG [2]
  • 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