Acute myocarditis

Cardiovascular

Clinicals - History

Fact Explanation
Symptoms of heart failure Patients can present with acute onset dyspnea, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and dependent edema are due to acute heart failure. Rapidly progressing heart failure is commonly seen in giant cell myocarditis. Symptoms of heart failure
Patients can present with acute onset dyspnea, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and dependent edema are due to acute heart failure. Rapidly progressing heart failure is commonly seen in giant cell myocarditis.
Chest pain Some patients with myocarditis may complain of chest pain. Chest pain
Some patients with myocarditis may complain of chest pain.
Fever Fever occurs due to inflammation of the myocardium. Sweating and chills can be associated with fever. Sometimes fever may be a preceding non-specific symptom. Fever
Fever occurs due to inflammation of the myocardium. Sweating and chills can be associated with fever. Sometimes fever may be a preceding non-specific symptom.
Dyspnea Most of the patients have dyspnea. This might be attributed to the development of heart failure and also to preceding viral upper respiratory tract infection. Dyspnea can be either at rest or with exertion. Dyspnea
Most of the patients have dyspnea. This might be attributed to the development of heart failure and also to preceding viral upper respiratory tract infection. Dyspnea can be either at rest or with exertion.
History of recent viral illness Post viral acute myocarditis can occur within 1to 2 weeks of viral illness. Flu and other upper respiratory tract infections and gastrointestinal infections can result in viral myocarditis. Before the onset of symptoms of heart failure patient may complain of fatigue, dyspnea, palpitations, malaise, and non-specific chest discomfort. History of recent viral illness
Post viral acute myocarditis can occur within 1to 2 weeks of viral illness. Flu and other upper respiratory tract infections and gastrointestinal infections can result in viral myocarditis. Before the onset of symptoms of heart failure patient may complain of fatigue, dyspnea, palpitations, malaise, and non-specific chest discomfort.
Palpitations Due to ventricular arrhythmias or atrio-ventricular block. This is a non-specific symptom. Palpitations
Due to ventricular arrhythmias or atrio-ventricular block. This is a non-specific symptom.
Syncope Can occur secondary to ventricular arrhythmias or atrio-ventricular block. Syncope
Can occur secondary to ventricular arrhythmias or atrio-ventricular block.
Sudden cardiac death A relatively rare presentation and is due to ventricular arrhythmias or atrio-ventricular block. Sudden cardiac death
A relatively rare presentation and is due to ventricular arrhythmias or atrio-ventricular block.
History of drug ingestion Certain drugs like phenothiazines and other anti-epileptics can cause myocarditis. History of drug ingestion
Certain drugs like phenothiazines and other anti-epileptics can cause myocarditis.
Skin rash Pruritic, maculopapular or generalized erythematous skin rash can occur in drug induced myocarditis. Skin rash
Pruritic, maculopapular or generalized erythematous skin rash can occur in drug induced myocarditis.
History of pregnancy Postpartum myocarditis can occur during the last trimester of pregnancy or within 5 months following delivery. History of pregnancy
Postpartum myocarditis can occur during the last trimester of pregnancy or within 5 months following delivery.

Clinicals - Examination

Fact Explanation
Pulse Tachycardia can occur due to heart failure. Arrhythmias can also be detected. Sustained ventricular tachycardia is seen in giant cell myocarditis. Pulse
Tachycardia can occur due to heart failure. Arrhythmias can also be detected. Sustained ventricular tachycardia is seen in giant cell myocarditis.
Gallop rhythm Third heart sound can occur due to heart failure. First heart sound can be diminished. Gallop rhythm
Third heart sound can occur due to heart failure. First heart sound can be diminished.
Pulmonary crackles Diffuse pulmonary crackles are heard due to pulmonary edema secondary to heart failure. Pulmonary crackles
Diffuse pulmonary crackles are heard due to pulmonary edema secondary to heart failure.
Mitral regurgitation A murmur of mitral regurgitation can occur. Mitral regurgitation
A murmur of mitral regurgitation can occur.
Tricuspid regurgitation Murmur of tricuspid regurgitation can present. Tricuspid regurgitation
Murmur of tricuspid regurgitation can present.
Edema Due to heart failure. Peripheral and dependent edema is seen. Edema
Due to heart failure. Peripheral and dependent edema is seen.
Pericardial friction rub A pericardial rub can rarely occur in myocarditis if the patient has pericarditis as well. Pericardial friction rub
A pericardial rub can rarely occur in myocarditis if the patient has pericarditis as well.
Lymphadenopathy Lymphadenopathy is seen in sarcoid myocarditis. Lymphadenopathy
Lymphadenopathy is seen in sarcoid myocarditis.
Skin involvement Maculopapular rash is seen in drug induced myocarditis. Skin involvement
Maculopapular rash is seen in drug induced myocarditis.

Investigations - Diagnosis

Fact Explanation
Full blood count Leukocytosis is seen due to inflammation. Full blood count
Leukocytosis is seen due to inflammation.
Erythrocyte sedimentation rate Elevated due to inflammation, but this has very low sensitivity and specificity. Erythrocyte sedimentation rate
Elevated due to inflammation, but this has very low sensitivity and specificity.
C-reactive protein Elevated due to inflammation. C-reactive protein
Elevated due to inflammation.
Electrocardiogram (ECG) ECG changes are often nonspecific. Sometimes sinus tachycardia and ventricular arrhythmia can be detected. Nonspecific ST- or T-wave changes, PQ-segment depression can also be seen. Sometimes ST segment elevation can mimic ECG changes of a myocardial infarction. Electrocardiogram (ECG)
ECG changes are often nonspecific. Sometimes sinus tachycardia and ventricular arrhythmia can be detected. Nonspecific ST- or T-wave changes, PQ-segment depression can also be seen. Sometimes ST segment elevation can mimic ECG changes of a myocardial infarction.
Chest X-ray Features of heart failure (pulmonary edema, Kerley B lines, upper lobe diversion, pleural effusions) can be seen. Chest X-ray
Features of heart failure (pulmonary edema, Kerley B lines, upper lobe diversion, pleural effusions) can be seen.
Cardiac enzymes Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Creatine kinase or cardiac troponins are commonly assessed. Cardiac troponin (troponin I or T). identify patients with resolution of viral myocarditis, better than creatinine kinase MB. Cardiac enzymes
Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Creatine kinase or cardiac troponins are commonly assessed. Cardiac troponin (troponin I or T). identify patients with resolution of viral myocarditis, better than creatinine kinase MB.
Serum viral antibody titers Viral antibody titers can be assessed if post viral myocarditis is suspected. Commonly group B coxsackie virus, parvovirus B19, human immunodeficiency virus, cytomegalovirus, Ebstein-Barr virus, hepatitis viruses, and influenza viruses can cause myocarditis. Serum viral antibody titers
Viral antibody titers can be assessed if post viral myocarditis is suspected. Commonly group B coxsackie virus, parvovirus B19, human immunodeficiency virus, cytomegalovirus, Ebstein-Barr virus, hepatitis viruses, and influenza viruses can cause myocarditis.
Endomyocardial biopsy Endomyocardial biopsy samples are used to assess the presence of viral genomes (by viral polymerase chain reaction) and also used for histological diagnosis of myocarditis. Lymphocyte infiltration and myocyte necrosis are histological findings. Dallas criteria are used for the histological diagnosis of myocarditis. Endomyocardial biopsy
Endomyocardial biopsy samples are used to assess the presence of viral genomes (by viral polymerase chain reaction) and also used for histological diagnosis of myocarditis. Lymphocyte infiltration and myocyte necrosis are histological findings. Dallas criteria are used for the histological diagnosis of myocarditis.
Echocardiography Echocardiogram can roughly locate the site of inflammation. Abnormal wall motions, enlarged left ventricle, diastolic dysfunction and the presence of pericardial effusion are suggestive of myocarditis. Echocardiography
Echocardiogram can roughly locate the site of inflammation. Abnormal wall motions, enlarged left ventricle, diastolic dysfunction and the presence of pericardial effusion are suggestive of myocarditis.
Gadolinium scan This is a very sensitive test to assess the extent of inflammation and cellular edema. Gadolinium scan
This is a very sensitive test to assess the extent of inflammation and cellular edema.
Cardiac MRI Cardiac MRI has sensitivity of 100% and specificity of 90% in diagnosing myocarditis by detecting sites of inflammation. Cardiac MRI
Cardiac MRI has sensitivity of 100% and specificity of 90% in diagnosing myocarditis by detecting sites of inflammation.
Autoantibodies Autoimmune etiology is also responsible for the development of myocarditis. Screening of common cardiac autoantibodies (antibodies against cardiac myosin heavy chain) is helpful in diagnosing. Autoantibodies
Autoimmune etiology is also responsible for the development of myocarditis. Screening of common cardiac autoantibodies (antibodies against cardiac myosin heavy chain) is helpful in diagnosing.

Management - Supportive

Fact Explanation
Basic life support Assessment of the airway, breathing and circulation should be the first step in patient management. Oxygen should be delivered if necessary. Patient should be connected to a cardiac monitor. Administration of intravenous fluid is considered if necessary. Some patients with severe cardiac failure and cardiogenic shock may require mechanical cardiac support. Basic life support
Assessment of the airway, breathing and circulation should be the first step in patient management. Oxygen should be delivered if necessary. Patient should be connected to a cardiac monitor. Administration of intravenous fluid is considered if necessary. Some patients with severe cardiac failure and cardiogenic shock may require mechanical cardiac support.
Vaccination Vaccination against measles, rubella, mumps, poliomyelitis, and influenza can prevent myocarditis caused by those infections. Vaccination
Vaccination against measles, rubella, mumps, poliomyelitis, and influenza can prevent myocarditis caused by those infections.
Dietary advice Patients are advised to consume a low-sodium diet and to restrict fluid as it can cause a state of fluid overload. Dietary advice
Patients are advised to consume a low-sodium diet and to restrict fluid as it can cause a state of fluid overload.
Physical rest Bed rest is recommended for all patients. Patients should seek medical advice before the commencement of strenuous activities. Physical rest
Bed rest is recommended for all patients. Patients should seek medical advice before the commencement of strenuous activities.
Stop the offending drug In drug induced myocarditis, the offending drug should be stopped. Stop the offending drug
In drug induced myocarditis, the offending drug should be stopped.
Treatment of infection In viral myocarditis, the underlying infection is better treated. Treatment of infection
In viral myocarditis, the underlying infection is better treated.
Antiarrhythmics Antiarrhythmics are indicated in arrhythmias. But caution should be applied as most of the antiarrhythmatics have negative inotropic actions. Antiarrhythmics
Antiarrhythmics are indicated in arrhythmias. But caution should be applied as most of the antiarrhythmatics have negative inotropic actions.

Management - Specific

Fact Explanation
Conservative management Most of the patients with post viral myocarditis may recover spontaneously. These patients only need supportive management of heart failure. Conservative management
Most of the patients with post viral myocarditis may recover spontaneously. These patients only need supportive management of heart failure.
Management of heart failure Diuretics, beta blockers and angiotensin-converting enzyme (ACE) inhibitors are preferred. Inotropic drugs (eg, dobutamine, milrinone) should be used whenever necessary. Management of heart failure
Diuretics, beta blockers and angiotensin-converting enzyme (ACE) inhibitors are preferred. Inotropic drugs (eg, dobutamine, milrinone) should be used whenever necessary.
Immune suppression Immune suppression is effective in patients with autoimmune myocarditis. Corticosteroids can be used for immune modulation but it does not reduce mortality. Immune suppression
Immune suppression is effective in patients with autoimmune myocarditis. Corticosteroids can be used for immune modulation but it does not reduce mortality.
Pace makers Patients with Mobitz type II or complete heart block usually require a temporary pacemaker. Permanent pacer or automatic implantable cardioverter-defibrillator (AICD) placement may be needed in some patients. Pace makers
Patients with Mobitz type II or complete heart block usually require a temporary pacemaker. Permanent pacer or automatic implantable cardioverter-defibrillator (AICD) placement may be needed in some patients.
Management of tachycrrhythmia Atrial tachycardia, and ventricular tachycardia are recognized complications of acute myocarditis. Antiarrhythmics should be prescribed to control these tachyarrhythmias. Management of tachycrrhythmia
Atrial tachycardia, and ventricular tachycardia are recognized complications of acute myocarditis. Antiarrhythmics should be prescribed to control these tachyarrhythmias.
Heart transplantation Cardiac transplantation may be needed especially in biopsy proven giant cell myocarditis. Heart transplantation
Cardiac transplantation may be needed especially in biopsy proven giant cell myocarditis.

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