Myocarditis

Lemma Z. (MD, Internist)

January, 2022
Introduction
• Myocarditis is an inflammatory disease of cardiac muscle.
• It can be acute, subacute, or chronic.
• Either focal or diffuse involvement of the myocardium.
Cont.
• Incidence : 22/100,000
• Etiology : Caused by a variety of infectious and noninfectious illnesses
• Viruses are most frequent pathogens.
• But bacteria, fungi, protozoa, and helminths have also been
implicated.
• Viral myocarditis — Viral infection is the most commonly identified
cause of lymphocytic myocarditis.
• The most common viral genomes identified in patients with suspected
myocarditis are human herpes virus 6 and parvovirus B19
Noninfectious causes
• Cardiotoxins Hypersensitivity reactions
Alcohol Antibiotics (penicillins, cephalosporins,
Anthracyclines sulfonamides)
Arsenic Clozapine
Carbon monoxide Diuretics (thiazide, loop)
Catecholamines Dobutamine
Cocaine Insect bites (bee, wasp, spider, scorpion)
Cyclophosphamide Lithium
Heavy metals (copper, lead, iron) Methyldopa
Snake bites
Hypersensitivity myocarditis
 Hypersensitivity myocarditis (HSM)
• A form of eosinophilic myocarditis
• Autoimmune reaction in the heart that is often drug-related.
• Characterized by acute rash, fever, peripheral eosinophilia, and ECG
abnormalities such as nonspecific ST segment changes or infarct
patterns.
• Some patients present with sudden death or rapidly progressive HF.
• HSM is usually temporally related to a recently initiated medication
• Usually characterized by an interstitial infiltrate with prominent
eosinophils.
Cont.
 VIRAL MYOCARDITIS AND DILATED CARDIOMYOPATHY
• The role of viral myocarditis in DCM is an important clinical issue.
• There are several potential mechanisms by which a viral myocarditis
might cause acute or chronic DCM
• Including direct viral damage or
• As a result of humoral or cellular immune responses to persistent viral
infection.
Cont.
• HIV — DCM, occasionally due to myocarditis, develops frequently in
advanced HIV infection and is associated with poor prognosis.
• DCM in HIV may be caused by toxicity of the gp120 protein, adverse
reaction to antiviral agents, or to opportunistic infections.
 Pathogenesis:
• Autoimmune mechanisms have been implicated in the pathogenesis
of myocarditis.
Cont.
• The clinical manifestations of myocarditis are highly variable:
• Subclinical disease.
• Fatigue, chest pain, heart failure
• Cardiogenic shock, arrhythmias, and sudden death
• Severe, diffuse myocarditis can result in acute dilated
cardiomyopathy.
Cont.
• In the early stages of viral myocarditis.
• For example, the patient may have fever, myalgias, and muscle tenderness.
• Myocarditis may present with unexpected sudden death, presumably
due to ventricular tachycardia or fibrillation.
• S3 and occasionally S4 gallops are important signs of impaired
ventricular function.
• Biventricular acute myocardial involvement results in systemic and
pulmonary congestion.
Cont.
• If the right or left ventricular dilation is severe, auscultation may
reveal murmurs of functional mitral or tricuspid insufficiency.
• A pericardial friction rub and/or effusion may be detected in some
patients with myocarditis and associated pericarditis
(myopericarditis).
Cont.
• Echocardiography :Is the key method of detecting impaired
ventricular function in suspected myocarditis.
• Findings include left ventricular dilation, changes in left ventricular
geometry (eg, development of a more spheroid shape), and wall
motion abnormalities.
• The systolic dysfunction is generally global.
• Cardiovascular magnetic resonance-The pattern of late gadolinium
enhancement (LGE) in myocarditis.
DIAGNOSIS
• Acute myocarditis should be suspected in the following clinical
settings:
• Onset of otherwise unexplained cardiac abnormalities such as heart
failure, cardiogenic shock, or arrhythmias.
• Age at onset varies but is typically between 20 to 50 years.
• Some patients have history of a viral illness or have rash and eosinophilia
following a new drug or vaccine.
Cont.
• Acute or subacute development of left ventricular (LV) systolic
dysfunction (global or regional) without apparent etiology.
• Diagnosis clinical presentation and noninvasive diagnostic findings
including typical CMR abnormalities.
• A definitive diagnosis of myocarditis is based upon endomyocardial
biopsy (EMB).
• Once other causes of heart failure (such as IHD, critical valvular lesions, and
restrictive and hypertrophic cardiomyopathies) have been excluded.
Treatment
• Treatment of myocarditis includes general measures, including HF
therapy and treatment of arrhythmias.
Immunosuppressive therapy is suggested for specific autoreactive
disorders such as giant cell myocarditis, sarcoidosis, noninfectious
eosinophilic myocarditis.
• Autoreactive myocarditis in the context of known extra-cardiac autoimmune
disease (eg, lupus myocarditis).
• Patients with myocarditis should avoid nonsteroidal antiinflammatory
drugs, heavy alcohol consumption, and exercise.
Cont.
• There is currently no specific therapy recommended during any stage
of viral myocarditis.
During acute infection, therapy with antiinflammatory or
immunosuppressive medications is avoided.
As their use has been shown to increase viral replication and
myocardial injury.
Thank You!