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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
| | {{Myocarditis}} |
| Image = Viral myocarditis (1).JPG |
| | '''For the WikiPatient page for this topic, click [[{{PAGENAME}} (patient information)|here]]''' |
| Caption = Histopathological image of viral myocarditis at autopsy in a patient with acute onset of congestive heart failure. Viral etiology, however, failed to be determined in postmortem serological study. |
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| DiseasesDB = 8716 |
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| ICD10 = {{ICD10|I|09|0|i|05}}, {{ICD10|I|51|4|i|30}} |
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| ICD9 = {{ICD9|391.2}}, {{ICD9|422}}, {{ICD9|429.0}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000149 |
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| eMedicineSubj = med |
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| eMedicineTopic = 1569 |
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| eMedicine_mult = {{eMedicine2|emerg|326}} |
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| MeshID = D009205 |
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| }}
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| {{SI}}
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| {{WikiDoc Cardiology Network Infobox}}
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| '''Editors-In-Chief:''' Josh Hare, M.D.; [[C. Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]
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| '''Associate Editor-In-Chief:''' {{CZ}} | | '''Editors-In-Chief:''' [[C. Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief: ''' {{Homa}}[[Varun Kumar|Varun Kumar, M.B.B.S.]]; {{CZ}}; {{Maliha}} |
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| {{Editor Join}} | | {{SK}} [[Inflammatory cardiomyopathy]]; [[Idiopathic myocarditis]]; [[Viral cardiomyopathy]]; [[inflammation of the heart muscle]]; [[myocardium inflammation]]; [[bacterial myocarditis]]; [[viral myocarditis]]; [[fungal myocarditis]]; [[spirochaetal myocarditis]]; [[protozoal myocarditis]]; [[parasitic myocarditis]]; [[rickettsial myocarditis]]; [[autoimmune myocarditis]]; [[immune-mediated myocarditis]]; [[allergen-mediated myocarditis]]; [[alloantigen-mediated myocarditis]]; [[autoantigen-mediated myocarditis]]; [[toxic myocarditis]]; [[dug-mediated myocarditis]]; [[drug-related myocarditis]]; [[acute myocarditis]]; [[chronic myocarditis]]; [[sarcoidosis-related myocarditis]]; [[giant cell myocarditis]]; [[autoreactive myocarditis]]; [[healed myocarditis]]; [[pediatric myocarditis]]; [[myocarditis in children]]; [[children myocarditis]]; [[pediatric inflammatory cardiomyopathy]]; [[pediatric inflammation of heart muscle]]; [[Inflammatory cardiomyopathy in children]]; [[inflammation of the heart muscle in children]]; [[Postviral autoimmune-related myocarditis]]; [[Infectious myocarditis]]; [[hypersensitivity myocarditis]]; [[fulminant myocarditis]], [[eosinophilic myocarditis]] |
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| '''Myocarditis''' is [[inflammation]] of the [[myocardium]], the muscular part of the [[heart]]. It is generally due to [[infection]] ([[virus|viral]] or [[bacterium|bacterial]]). It may present with [[chest pain]], rapid signs of [[heart failure]], or [[sudden death]].
| | ==[[Myocarditis overview|Overview]]== |
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| ==Epidemiology== | | ==[[Myocarditis historical perspective|Historical Perspective]]== |
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| The exact incidence of myocarditis is unknown. However, in series of routine [[autopsy|autopsies]], 1–9% of all patients had evidence of myocardial inflammation. In young adults, up to 20% of all cases of [[sudden death]] are due to myocarditis.
| | ==[[Myocarditis classification|Classification]]== |
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| In South America, [[Chagas' disease]] (caused by ''[[Trypanosoma cruzi]]'') is the main cause of myocarditis.
| | ==[[Myocarditis pathophysiology|Pathophysiology]]== |
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| ==Signs and symptoms== | | ==[[Myocarditis causes|Causes]]== |
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| The signs and symptoms associated with myocardits are varied, and relate either to the actual inflammation of the [[myocardium]], or the weakness of the heart muscle that is secondary to the inflammation. Signs and symptoms of myocarditis include:<ref name=Feldman>Feldman AM, McNamara D. Myocarditis. ''[[New England Journal of Medicine|N Engl J Med]]'' 2000;343:1388-98. PMID 11070105.</ref>
| | ==[[Myocarditis differential diagnosis|Differentiating Myocarditis from other Diseases]]== |
| * [[Chest pain]] (often described as "stabbing" in character)
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| * [[Congestive heart failure]] (leading to [[edema]], [[breathlessness]] and [[Liver|hepatic]] congestion)
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| * [[Palpitation]]s (due to [[arrhythmia]]s)
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| * [[Sudden death]] (in young adults, myocarditis causes up to 20% of all cases of [[sudden death]])<ref>Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, Pearse LA, Virmani R. Sudden death in young adults: a 25-year review of autopsies in military recruits. ''Ann Intern Med'' 2004;141:829-34. PMID 15583223.</ref>
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| * [[Fever]] (especially when infectious, e.g. in [[rheumatic fever]])
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| Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent with a recent viral infection, including [[fever]], [[diarrhea]], [[joint pains]], and easy fatigueability.
| | ==[[Myocarditis epidemiology|Epidemiology and Demographics]]== |
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| Myocarditis is often associated with [[pericarditis]], and many patients present with signs and symptoms that suggest concurrent myocarditis and [[pericarditis]].
| | ==[[Myocarditis natural history|Natural History, Complications and Prognosis]]== |
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| == Diagnosis == | | ==Diagnosis== |
| | | [[Myocarditis history and symptoms|History and Symptoms]] | [[Myocarditis physical examination|Physical Examination]] | [[Myocarditis laboratory findings|Laboratory Findings]] | [[Myocarditis electrocardiogram|Electrocardiogram]] | [[Myocarditis endomyocardial biopsy|Endomyocardial Biopsy]] | [[Myocarditis chest x ray|Chest X Ray]] | [[Myocarditis MRI|MRI]] | [[Myocarditis echocardiography|Echocardiography]] | [[Myocarditis other imaging findings|Other Imaging Findings]] | [[Myocarditis other diagnostic studies|Other Diagnostic Studies]] |
| Myocardial inflammation can be suspected on the basis of [[electrocardiogram|electrocardiographic]] results (ECG), elevated [[C-reactive protein|CRP]] and/or [[Erythrocyte sedimentation rate|ESR]] and increased [[IgM]] ([[serology]]) against viruses known to affect the [[myocardium]]. Markers of myocardial damage ([[troponin]] or [[creatine kinase]] cardiac isoenzymes) are elevated.<ref name=Feldman/>
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| ===Electrocardiographic Findings===
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| The [[electrocardiogram|ECG]] findings most commonly seen in myocarditis are [[sinus tachycardia]], diffuse [[T wave]] inversions; [[ST segment]] elevation may also be present (these are also seen in pericarditis).<ref name=Feldman/>
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| ===Endomyocardial Biopsy===
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| The [[gold standard (test)|gold standard]] is still [[biopsy]] of the [[myocardium]], generally done in the setting of [[angiography]]. A small tissue sample of the [[endocardium]] and [[myocardium]] is taken, and investigated by a pathologist by and if necessary[[immunochemistry]] and special staining methods. Histopathological features are: myocardial interstitium with abundant edema and inflammatory infiltrate, rich in [[lymphocyte]]s and [[macrophage]]s. Focal destruction of myocytes explains the myocardial pump failure.<ref name=Feldman/>
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| ===Cardiac Magnetic Resonance Imaging===
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| Recently, cardiac [[magnetic resonance imaging]] (cMRI or CMR) has been shown to be very useful in diagnosing myocarditis by visualizing markers for [[inflammation]] of the [[myocardium]].<ref>{{cite journal |author=Skouri HN, Dec GW, Friedrich MG, Cooper LT |title=Noninvasive imaging in myocarditis |journal=J. Am. Coll. Cardiol. |volume=48 |issue=10 |pages=2085-93 |year=2006 |pmid=17112998 |doi=10.1016/j.jacc.2006.08.017}}</ref>
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| == Differential Diagnosis of Underlying Causes ==
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| A large number of different causes have been identified as leading to myocarditis:<ref name=Feldman/>
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| ===[[Infectious disease|Infectious]]===
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| *[[Virus|Viral]]
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| :*[[Enterovirus]]
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| :*[[Coxsackie virus]]
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| :*[[Rubella virus]]
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| :*[[Polio virus]]
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| :*[[Cytomegalovirus]]
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| :*[[Adenoviruses]]
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| :*[[Arboviruses]]
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| :*[[Coxsackie virus|Coxsackie virus A]]
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| :*[[Coxsackie virus|Coxsackie virus B1-B5]]
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| :*[[CMV]]
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| :*[[Echovirus]]
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| :*[[Epstein-Barr virus]]
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| :*[[Flavivirus]]
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| :*[[Hepatitis|Hepatitis virus]]
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| :*:*[[Hepatitis C]]
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| :*[[HIV]]
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| :*[[Influenza]]
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| :*[[Measles virus]]
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| :*[[Mumps|Mumps virus]]
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| :*[[Polio|Polio virus]]
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| :*[[Rabies|Rabies virus]]
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| :*[[Varicella Zoster Virus]]
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| * [[Bacterium|Bacterial]]
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| :*[[Actinomyces]]
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| :*[[Whipple's disease|Tropheryma whipplei]]
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| :*[[Vibrio cholerae]]
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| :*[[Group A streptococcal infection|Beta hemolytic Streptococci]]
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| :*[[Brucella]]
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| :*[[Corynebacterium diphtheriae]]
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| :*[[Enterococci]]
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| :*[[Gonococcus]]
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| :*[[Legionella]]
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| :*[[Meningococci]]
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| :*[[Pertussis]]
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| :*[[Psittacosis]]
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| :*[[Rickettsia]]
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| :*[[Salmonella]]
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| :*[[Syphilis|T. Pallidum]]
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| :*[[Staphylococci]]
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| :*[[Tetanus|Clostridium Tetani]]
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| :*[[Tuberculosis]]
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| :*[[Tularemia]]
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| :*[[Spirochete|Spirochetal]]
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| :*:*[[Borrelia burgdorferi]]
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| :*:*[[Leptospirosis]]
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| *[[Protozoa]]l
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| :*[[Toxoplasma gondii]]
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| :*[[Trypanosoma cruzi]]
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| * [[Fungus|Fungal]]
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| :*[[Aspergillus]]
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| * [[Parasite|Parasitic]]
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| :*[[Ascaris]]
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| :*[[Echinococcus granulosus]]
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| :*[[Paragonimus westermani]]
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| :*[[Schistosoma]]
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| :*[[Taenia solium]]
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| :*[[Trichinella spiralis]]
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| :*[[Visceral larva migrans]]
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| :*[[Wuchereria bancrofti]]
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| ===[[Immunology|Immunological]]===
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| * [[Allergy|Allergic]]
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| :*[[Acetazolamide]]
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| :*[[Amitriptyline]]
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| * [[heart transplant|Rejection after a heart transplant]]
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| * [[Autoimmune disorder|Autoantigens]]
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| :*[[Vasculitis|systemic vasculitis]]
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| :*[[Churg-Strauss syndrome]]
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| :*[[Wegener's granulomatosis]]
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| ===[[Toxicology|Toxic]]===
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| *[[Medication|Drugs]]
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| :*[[Anthracycline]]s
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| :*[[Chemotherapy]]
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| :*[[Ethanol]]
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| :*[[Antipsychotic]]s
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| :*:*[[Clozapine]]
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| :*[[Remicaid]]
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| * [[Toxin]]s
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| :*[[Arsenic]]
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| :*[[Carbon monoxide]]
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| :*[[Snake venom]]
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| * [[Heavy metals]]
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| :*[[Copper]]
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| :*[[Iron]]
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| ===Physical agents===
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| * [[Electric shock]]
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| * [[Fever|Hyperpyrexia]]
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| * [[Radiation]]
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| Bacterial myocarditis is rare in patients without [[immunodeficiency]].
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| ===The Heart in Toxoplasma Gondii Myocarditis===
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| <youtube v=2s9OuW9XlUw/>
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| ===The Heart in Coxsackie B2 Myocarditis===
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| <youtube v=R_7AXF61QGg/>
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| ==Treatment== | | ==Treatment== |
| Bacterial infections are treated with [[antibiotic]]s, dependent on the nature of the pathogen and its sensitivity to antibiotics. As most viral infections cannot be treated with directed therapy, symptomatic treatment is the only form of therapy for those forms of myocarditis, e.g. [[NSAID]]s for the inflammatory component and [[diuretic]]s and/or [[inotrope]]s for ventricular failure. [[ACE inhibitor]] therapy may aid in left ventricular remodeling after the inflammation has begun to resolve.
| | [[Myocarditis medical therapy|Medical Therapy]] | [[Myocarditis surgery|Surgery]] | [[Myocarditis primary prevention|Primary Prevention]] | [[Myocarditis secondary prevention|Secondary Prevention]] | [[Myocarditis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Myocarditis future or investigational therapies|Future or Investigational Therapies]] |
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| ==Pathologic Findings==
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| ===Autopsy Study===
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| ===Clinical Summary===
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| A 21-year-old male with [[sickle cell anemia]] had recurrent attacks of [[acute rheumatic fever]] beginning at age 14.
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| [[Mitral insufficiency]] and [[mitral stenosis|stenosis]] were present by age 16.
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| On prophylactic antibiotics, the patient had no evidence of recurrence until three weeks before his final admission, when an upper respiratory infection developed. A few weeks later he developed acute migratory polyarthritis. This was associated with rapid deterioration of cardiac function and death.
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| ===Autopsy Findings===
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| At autopsy, the heart was enlarged (weighing 675 grams) especially the [[left atrium]]. Both the [[aortic valve|aortic]] and [[mitral valve]]s showed fibrosis as well as the fresh, tiny verrucae characteristic of [[acute rheumatic fever]].
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| ===Images===
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| [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="225" widths="225">
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| Image:Acute rheumatic myocarditis case 1.jpg|This is a gross photograph of mitral valve demonstrating marked thickening and fibrosis of the valve leaflet. There are also numerous foci of fibrinoid necrosis within the cusps and friable vegetations (verrucae) along the lines of closure (arrows). These irregular, warty projections are found at sites of erosion on the inflamed endocardial surface. The verrucae probably result from the precipitation of fibrin where the leaflets impinge on each other.
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| Image:Acute rheumatic myocarditis case 2.jpg|This is a low-power photomicrograph of heart tissue. Little can be seen at this magnification, except that the tissue looks relatively normal.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="225" widths="225">
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| Image:Acute rheumatic myocarditis case 3.jpg|This is a higher-power photomicrograph of myocardium showing cellular accumulations--Aschoff bodies (arrows)--within the interstitium of the myocardium. These are found especially around blood vessels.
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| Image:Acute rheumatic myocarditis case 4.jpeg|This is a higher-power photomicrograph of myocardium containing Aschoff bodies (arrows) within the interstitium.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="225" widths="225">
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| Image:Acute rheumatic myocarditis case 5.jpeg|This high-power photomicrograph of myocardium shows the cellular detail of an Aschoff body. Aschoff bodies are foci of fibrinoid necrosis surrounded by lymphocytes, macrophages, an occasional plasma cell, and plump “activated” histiocytes called Anitschkow cells or Aschoff cells (arrows). These distinctive cells have abundant amphophilic cytoplasm and central round-to-ovoid nuclei in which the chromatin is disposed in a central, slender, wavy ribbon resembling a caterpillar (hence the designation “caterpillar cells”).
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| Image:Acute rheumatic myocarditis case 6.jpeg|This high-power photomicrograph of myocardium shows the cellular detail of another Aschoff body. In this case there appears to be a multinucleated Aschoff giant cell (arrow).
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| </gallery>
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| </div>
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| ==References==
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| {{Reflist|2}}
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| ==External links==
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| * [http://www.pathologyatlas.ro/Viral%20Myocarditis.html Histopathology images of myocarditis]
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| * [http://www.emedicine.com/emerg/topic326.htm eMedicine: Myocarditis]
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| * [http://www.antibodypatterns.com/cardiacmusclebody.php Carditis related antibody]
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| {{Circulatory system pathology}}
| | ==Case Studies== |
| {{Electrocardiography}}
| | [[Myocarditis case study one|Case #1]] |
| {{SIB}}
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| [[de:Myokarditis]]
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| [[es:Miocarditis]] | | [[es:Miocarditis]] |
| [[fr:Myocardite]] | | [[fr:Myocardite]] |
| [[it:Miocardite]]
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| [[ja:心筋炎]] | | [[ja:心筋炎]] |
| [[pt:Miocardite]] | | [[pt:Miocardite]] |
| [[fi:Sydänlihastulehdus]]
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| [[sv:Hjärtmuskelinflammation]]
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| [[vi:Viêm cơ tim]] | | [[vi:Viêm cơ tim]] |
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