Acute viral myocarditis

Acute Viral

MyocarditisProf. Dr. Saad S al Ani

Senior Pediatric Consultant

Head of Pediatric Department

Khorfakkan Hospital ,Sharjah ,UAE

[email protected]

mailto:[email protected]

Myocarditis

Myocarditis is an inflammatory disease of

the cardiac muscle caused by myocardial

infiltration of immunocompetent cells

following any kind of cardiac injury

2/3/2015Acute myocarditis Prof. Dr. Saad S Al Ani Khorfakkan Hospital 2

http://eurheartj.oxfordjournals.org

http://eurheartj.oxfordjournals.org/

Acute myocarditis

Is often a result of a viral infection that produces

myocardial necrosis and triggers an immune

response to eliminate the infectious agent

2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 3

Causes


Viral Infections are the most common

etiology though myocardial toxins ,drug

exposures ,hypersensitivity reactions ,and

immune disorders

Causes (cont.)

Coxsackievirus and other enteroviruses,

adenovirus, parvovirus, Epstein-Barr virus, and

cytomegalovirus are the most common causative

agents in children


RNA viruses

Picornaviruses

Togaviruses

FlavivirusesParamyxoviruses

Orthomyxovirus


Coxsackie A + BEchovirus

PoliovirusHepatitis virus

Influenza

Respiratory Syncitial virus

Mumps

Rubella

Dengue Fever

Yellow Fever

DNA viruses

Adenovirus

Retrovirus

Herpesviruses

Erythrovirus


A 1, 2 ,3, and 5

1 (B19V) and 2

Human herpes virus 6 A/B

Cytomegalovirus

HIV

Epstein-Barr virusVaricella-zoster virus

EpidemiologyManifestations are age dependent:

• In infants

viral myocarditis can be fulminant

• In children

acute, myopericarditis with congestive heart

failure

• In older children and adolescents

acute or chronic congestive heart failure.








Clinical Manifestations

Sudden death

Acute cardiogenic shock

Asymptomatic or nonspecific generalized illness


• Children with myocarditis present with

symptoms that can be mistaken for other types

of illnesses; respiratory presentations were

most common.


Clinical Manifestations (cont.)

Infants and young children

Fulminant presentation

Fever, Respiratory distress, Tachycardia,Hypotension, Gallop rhythm, and Cardiacmurmur

Associated findings may include a rash orevidence of end organ involvement such ashepatitis or aseptic meningitis



Patients with acute or chronic myocarditis

Presentation:

Chest discomfort, Fever, Palpitations, Easyfatigability, or Syncope/Near syncope



Cardiac findings

Overactive precordial impulse, Galloprhythm, and Apical systolic murmur ofmitral insufficiency

In patients with associated pericardialdisease, a rub may be noted



Patient with decompensated congestive heart failure

-Hepatic enlargement

-Peripheral edema

-Pulmonary findings such as wheezes orrales


Diagnosis• Electrocardiographic changes

1. Are nonspecific

2. May include:

i. Sinus tachycardia

ii. Atrial or ventricular arrhythmias

iii. Heart block

iv. Diminished QRS voltages

v. Nonspecific ST and T-wave changes often suggestive of acute ischemia.


Diagnosis (cont.)

• Chest roentgenograms

In severe, symptomatic cases reveal:

1. Cardiomegaly

2. Pulmonary vascular prominence

3. Overt pulmonary edema

4. Pleural effusions.


Diagnosis(cont.)

• Echocardiography

Often shows:

1. Diminished ventricular systolic function

2. Cardiac chamber enlargement

3. Mitral insufficiency

4. Pericardial infusion (occasionally)


Diagnosis(cont.)

• Endomyocardial biopsy

May be useful in identifying inflammatory

cell infiltrates or myocyte damage

• Molecular viral analysis using polymerase

chain reaction (PCR) techniques.


Diagnosis(cont.)

• Catheterization and biopsy

Should be performed in:

i. Patients suspected to have myocarditis

ii. If there is strong suspicion for unusual

forms of cardiomyopathy such as storage

diseases or mitochondrial defects


Diagnosis(cont.)

• Supportive but nonspecific tests include

1. Sedimentation rate

2. CPK isoenzymes

3. Cardiac troponin I

4. Brain natriuretic peptide (BNP) levels


Differential diagnosis

* Carnitine deficiency

* Other metabolic disorders of energy generation

*Hereditary mitochondrial defects

*Idiopathic dilated cardiomyopathy

*Pericarditis

*Anomalies of the coronary arteries


Management• Primary therapy for acute myocarditis is

supportive

• Acutely, the use of inotropic agents, preferably

milrinone, should be entertained but used with

caution because of their pro-arrhythmic

potential.

• Diuretics are often required as well.


Management (cont.)

• In extremis, mechanical ventilatory supportand mechanical circulatory support with:

*Ventricular assist device implantation or

*ECMO

May be needed to:

*Stabilize the patient’s hemodynamic status

*Act as a bridge to recovery or cardiac

transplantation.


Management (cont.)

• In patients with compensated congestive heart

failure in the outpatient setting:

* Diuretics

*Angiotensin-converting enzyme inhibitors

*Angiotensin receptor blockers

are of use but may be contraindicated in those

presenting with fulminant heart failure and

cardiovascular collapse.


Management (cont.)

Significant atrial or ventricular arrhythmias:

• Specific antiarrhythmic agents ( amiodarone)

should be administered and ICD placement

considered.

• Immunomodulation is controversial.


Management (cont.)

• Intravenous immune globulin may have a role

in the treatment of acute or fulminant

myocarditis

• Corticosteroids ?


Management (cont.)

• Relapse has been noted in patients receiving

immunosuppression

• Specific antiviral therapies ?


Prognosis • In newborns with symptomatic acute

myocarditis is poor, and 75% mortality

• In children and adolescents is better

• Persistent evidence of dilated cardiomyopathy

→ need for cardiac transplantation.

• Recovery of ventricular function has been

reported in 10-50% of patients


References

• Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. Sep

2008;29(17):2073-82.

• Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs.

2002;4(3):171-81

• Renko M, Leskinen M, Kontiokari T, et al. Cardiac troponin-I as a screening tool for

myocarditis in children hospitalized for viral infection. Acta Paediatr. Nov 4 2009

• Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric

myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics.

Dec 2007;120(6):1278-85.



Acute viral myocarditis

Health & Medicine

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myocarditis present

infants viral myocarditis

children acute

adolescents acute

suggestive of acute

myocardial toxins

common etiology