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Myocarditis

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Charles Gomersall

Aetiology

  • viral infection
    • enteroviruses especially Coxsackie B3 and B4
    • adenoviruses, especially in younger patients
    • hepatitis C virus
  • Chagas' disease
  • diphtheria

Pathogenesis

3 phases

  1. viral replication
  2. immune activation resulting in cytokine mediated disease
  3. remodeling leading to dilated cardiomyopathy

Clinical features

  • fever
  • symptoms of upper respiratory or gastrointestinal infection
  • chest pain
  • lymphocytosis
  • atrial and ventricular arrhythmias
  • cardiogenic shock

Investigations

ECG

  • widened QRS
  • left bundle branch block
  • ST and T wave changes
  • heart block

Echo

  • impaired systolic function
  • wall motion abnormalities

Endomyocardial biopsy

  • Not necessary in the stage of viral replication
  • Most useful between few days to weeks after resolution of a symptomatic viral infection
  • Frequency of positive biopsy in patients with myocarditis or dilated cardiomyopathy is low (approx 10%) but is higher in patients with acute early presentations of myocarditis

Treatment

  • in unusual cases where a virological diagnosis is established early anti-virals are indicated
  • at present there is no good evidence that either steroids or intravenous immunoglobulin improve outcome
  • aggressive supportive therapy including left ventricular assist device if necessary

Prognosis

  • patients with fulminant myocarditis who develop sudden haemodynamic compromise have a much better long term prognosis than those with mild acute or chronic forms.
  • in one study patients survival at 5.6 years was 93% in those with fulminant myocarditis

Further reading

Liu PP, Mason JW. Advances in the understanding of myocarditis. Circulation 2001; 104:1076-82

Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database of Systematic Reviews 2006 Issue 1

First posted 15th March 2006


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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