DEPARTMENT OF INTERNAL MEDICINE II AND PHTHYSIATRY

-RAJKUMAR SUBASARAVANAN
SUBGROUP ”12”
CASE:
• A 20-year-old woman, who had an unremarkable medical history and was immunocompetent, was admitted
to another hospital due to fever, fatigue, and anorexia, and she was administered acetaminophen and
antibiotics.
• She also experienced vomiting, as well as systemic myalgia 5 days after admission causing an inability to move.
• Her condition was worsening, and she was transferred to this hospital 7 days after her initial admission. Upon
admission, her liver enzyme and creatine phosphokinase (CPK or CK) levels were high.
• She reported only an occasional small amount of ethanol intake and had not had sexual intercourse.
• Additionally, she did not report any history of diabetes, hypertension, tuberculosis, thyroid disease, trauma,
exposure to industrial toxins or radiation, blood or blood component therapy, bleeding disorders, promiscuity,
or similar complaints in the family or neighborhood.
• Upon admission, her vital signs were as follows: body temperature, 37.2 °C; blood pressure, 110/72 mmHg;
pulse,75 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 98% on room air. A physical
examination revealed mild enlargement of the liver, no pitting edema in both legs, and no coarse crackles over
the lung fields.
Electrocardiography showed diffuse ST-segment elevation. Her troponin I, CK level in the blood (CK-MB),
and brain natriuretic peptide (BNP) were elevated (troponin-T, 0.879 ng/mL [normal value: ≤0.016 ng/mL]; CK-MB253 U/L
[normal value: ≤5U/L];BNP,1513pg/mL[normal value: ≤18.4 pg/mL]). Chest radiography showed a normal
cardiac size, pulmonary congestion, and pleural effusion in the right lung only . Echocardiography showed
a dilated, spherical ventricle with reduced systolic function (left ventricle ejection fraction [LVEF], 17%) and pericar-
dial effusion .
MYOCARDITIS:
Myocarditis is defined as an inflammatory disease of the heart muscle and is an important
cause of acute heart failure, sudden death, and dilated cardiomyopathy. The term myocarditis refers to an
inflammation of the heart muscle, which can be caused by infections, toxic substances, or autoimmune
processes. Myocarditis is defined by an inflammation of the myocardium diagnosed by established histological,
immunological, and immunohistochemical criteria.
ETIOLOGY AND PATHOGENESIS:
ANAMNESIS:
1. History of a preceding infections of various etiology
2. History of preceding autoimmune diseases
3. History of preceding Intoxication

PHYSICAL EXAMINATION:
• is often normal, although more severe cases may show a muffled first heart sound, along with a third
heart sound and a murmur of mitral regurgitation
• A pericardial friction rub may be audible in patients with associated pericarditis.
CLINICAL PRESENATIONS:
1. Acute chest pain
2. New-onset (days up to 3 months) or worsening of dyspnea at rest of exercise, and/ or fatigue, with or
without left and/or right heart failure signs
3. Subacute/chronic (>3 months) or worsening of: dyspnea at rest or exercise and/or fatigue, with or without
left and/or right heart failure signs
4. Palpitation, and/or unexplained arrhythmia symptoms and/or syncope, and/or aborted sudden cardiac
death
5. Unexplained cardiogenic shock
DIAGNOSTIC CRITERIA:
1. ECG/Holter/stress test features.
a. Newly abnormal ECG and/or Holter and/or stress testing, any of the following: I to III degree atrioventricular
block, or bundlebranch block, ST/T wave changes (ST elevation or non ST elevation, T wave inversion), sinus
arrest, ventricular tachycardia of fibrillation and asystole, atrial fibrillation, reduced T wave height, intraven-
tricular conduction delay (widened QRS complex), abnormal Q waves, low voltage, frequent premature beats,
supraventricular tachycardia.
2. Myocardiocytolysis markers a. Elevated TnT/TnI
3. Structural and functional abnormalities of cardiac imaging (echo/angio/CMR)
a. New, otherwise unexplained LV and/or RV structural and functional abnormality (including incidental finding in
apparently asymptomatic patients): regional wall motion or global systolic or diastolic function abnormality, with
or without ventric ular dilatation, with or without increased wall thickness, with or without pericardial effusion,
with or without endocavitary thrombi.
4. Tissue characterization by CMR
Clinically suspected myocarditis if ≥1 clinical presentation and ≥1 diagnostic criteria from different categories, it
the absence of: (1) angiographically detectable coronary artery disease (coronary stenosis ≥50%); (2) known pre-
existing cardiovascular dis- ease or extra-cardiac causes that could explain the syndrome.
If the patient is asymptomatic ≥2 diagnostic criteria should be met.
RECOMMENDATION OF LABORATORY EXAMS:
ECG FINDINGS OF MYOCARDITIS:
 Sinus tachycardia
 Wide QRS complexes
 QRS electrical alternans
 Prolonged QT interval
 Ventricular arrhythmias
 complete heart block with a junctional escape rhythm, ST segment elevation in leads I, aVL, aVR, and diffuse ST segment
depression in the other leads. CONCLUSION: Monomorphic Ventricular Tachycardia.
Diffuse ST elevation in almost all the leads mimicking ACS.
INDICATIONS OF ENDOMYOCARDIAL BIOPSY(EMB):
RECOMMENDATIONS FOR THE USE OF MRI IN
MYOCARDITIS:
 SCORE OF HLA-DR EXPRESSION INFLAMMATORY
INFILTRATION:

To establish a diagnosis of myocarditis, the HLA-DR positive score must be at least three or the ICAM-1 positive score
must be at least two; additionally, the presence of at least 7.0 inflammatory cells/mm2 should be observed. Scores from
one to three indicate a possible diagnosis of inflammation
MANAGEMENT AND TREATMENT:
NON-PHARMACOLOGICAL MEASURES:
GENERAL PHARMACOLOGICAL MEASURES:
SPECIFIC TREATMENT:
1.VIRAL MYOCARDITIS:
2. IMMUNE-MEDIATED MYOCARDITIS:
SUMMARY:
REFERENCES:
1. Harrison’s principles of internal medicine. Seventeenth Edition / Anthony S. Fauci,
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overview.
3. Nguyen V.Q. Dilated Cardiomyopathy [Electronic resource] / Vinh Q Nguyen. – 2017.
– Re- source access mode: https://emedicine.medscape.com/article/152696-
overview
4. Shah N.S. Hypertrophic Cardiomyopathy [Electronic resource] / Sandy N Shah. –
2016. – Re- source access mode: https://emedicine.medscape.com/article/152913-
overview
5. What is Cardiac Rehabilitation? [Electronic resource] – Resource access mode:
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Rehabilitation_ UCM_307049_Article.jsp#.WrApyea-k8o.
6. Tang W.H.W. Myocarditis [Electronic resource] / Wai Hong Wilson Tang. – 2016. –
Resource access mode: https://emedicine.medscape.com/article/156330-overview