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==Radiological Findings==
==Radiological Findings==
*In the past, most cases of myocardial abscess were found during autopsy. however, detection of myocardial abscess can now be achieved antemortem using multiple noninvasive imaging modalities, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), indium In 111 radionuclide scintigraphy, computed tomography (CT) scan, and magnetic resonance imaging (MRI).
*In the past, most cases of [[myocardial]] [[abscess]] were found during [[autopsy]]. however, detection of [[myocardial]] [[abscess]] can now be achieved antemortem using multiple [[noninvasive]] [[imaging]] modalities, including [[transthoracic echocardiography]] ([[TTE]]) and [[transesophageal echocardiography]] ([[TEE]]), [[indium]] In 111 [[radionuclide scintigraphy]], [[computed tomography]] ([[CT]]) [[scan]], and [[magnetic resonance imaging]] ([[MRI]]).


'''Chest radiography'''
'''[[Chest]] [[radiography]]'''
*chest radiography is perform to look for associated pulmonary infection.
*[[chest]] [[radiography]] is perform to look for associated [[pulmonary]] [[infection]].
Chest radiographic findings help assess for CHF.
*[[Chest]] [[radiographic]] findings help assess for [[CHF]].


'''Transthoracic echocardiography'''
'''[[Transthoracic echocardiography]]'''
*TTE helps evaluate patients in whom endocarditis or myocardial abscess is suggested clinically. Findings frequently allow the morphologic confirmation of infection and increasingly aid in making decisions regarding management.
*[[TTE]] helps evaluate patients in whom [[endocarditis]] or [[myocardial]] [[abscess]] is suggested clinically. Findings frequently allow the morphologic confirmation of infection and increasingly aid in making decisions regarding management.
*One must perform an echocardiographic evaluation in all patients suspected of having an intracardiac or pericardial infection, including those with negative blood culture findings.
*One must perform an [[echocardiographic]] evaluation in all patients suspected of having an intracardiac or [[pericardial infection]], including those with negative blood culture findings.
*TTE has a sensitivity of 23% and specificity of 98.6%.
*[[TTE]] has a sensitivity of 23% and specificity of 98.6%.
*According to Ellis et al (1985), the following 5 criteria are 86% sensitive and 88% specific for myocardial abscess:  
*According to Ellis et al (1985), the following 5 criteria are 86% sensitive and 88% specific for [[myocardial]] [[abscess]]:  
**Evidence of prosthetic valve rocking
**Evidence of [[prosthetic]] valve rocking
**Aneurysmal dilatation of the sinus of Valsalva
**[[Aneurysmal]] dilatation of the [[sinus]] of [[Valsalva]]
**Posterior aortic root thickness greater than 10 mm
**Posterior [[aortic root]] thickness greater than 10 mm
**Perivalvular density in the septum of greater than 14 mm
**[[Perivalvular]] density in the septum of greater than 14 mm
**The presence of "echo-free space" - Very specific but found relatively infrequently
**The presence of "echo-free space" - Very specific but found relatively infrequently
*Walker et al report a rare case of a myocardial abscess in valvular endocarditis that was difficult to assess with 2-dimensional TTE; however, real-time 3-dimensional contrast TTE allowed visualization of the full extent of the defect and its precise anatomical location, prior to successful surgical resection.  
*Walker et al report a rare case of a [[myocardial]] [[abscess]] in [[valvular]] [[endocarditis]] that was difficult to assess with 2-dimensional [[TTE]]; however, real-time 3-dimensional contrast [[TTE]] allowed [[visualization]] of the full extent of the defect and its precise [[anatomical]] location, prior to successful surgical resection.  


'''Transesophageal echocardiography'''
'''[[Transesophageal echocardiography]]'''
*Although many patients with NVE involving the aortic or mitral valve can be adequately assessed using TTE, TEE with color flow and continuous pulsed Doppler is the state-of-the-art technique. Doppler and color-flow Doppler or contrast 2-dimensional echocardiography helps optimally define fistulas and abscess pockets and extensions. See the image below.
*Although many patients with NVE involving the [[aortic]] or [[mitral valve]] can be adequately assessed using [[TTE]], [[TEE]] with color flow and continuous pulsed [[Doppler]] is the state-of-the-art technique. [[Doppler]] and color-flow Doppler or contrast 2-dimensional [[echocardiography]] helps optimally define fistulas and [[abscess]] pockets and extensions. See the image below.
*TEE has a sensitivity of 87% and specificity of 94.6%. Patients in whom an abscess is suggested but has not been detected using TEE should undergo MRI, including magnetic resonance angiography. ADD PIC
*[[TEE]] has a sensitivity of 87% and [[specificity]] of 94.6%. Patients in whom an [[abscess]] is suggested but has not been detected using [[TEE]] should undergo MRI, including [[magnetic resonance angiography]]. ADD PIC


'''Scintigraphy'''
'''[[Scintigraphy]]'''
*Indium In 111 leukocyte scintigraphy is especially useful in prosthetic valve endocarditis, in which echocardiography shows too much scatter.
*[[Indium]] In 111 [[leukocyte]] [[scintigraphy]] is especially useful in [[prosthetic]] [[valve]] [[endocarditis]], in which [[echocardiography]] shows too much scatter.
*A few milliliters of venous blood is drawn and mixed with an anticoagulant solution. The white blood cells are separated and labeled with radioactive isotope111 In, centrifuged, resuspended in isotonic sodium chloride solution, and reinjected into the patient. Images are then obtained with a gamma-ray camera within 16-24 hours. *The viable radioactive leukocytes potentially accumulate in the areas of inflammation or abscess. Obtain oblique views to avoid overshadowing by sternal accumulation.
*A few milliliters of [[venous]] [[blood]] is drawn and mixed with an [[anticoagulant]] solution. The [[white blood cell]]s are separated and labeled with [[radioactive]] isotope111 In, centrifuged, resuspended in [[isotonic]] [[sodium chloride]] solution, and reinjected into the patient. Images are then obtained with a [[gamma-ray]] camera within 16-24 hours. *The viable [[radioactive]] [[leukocytes]] potentially accumulate in the areas of [[inflammation]] or [[abscess]]. Obtain oblique views to avoid overshadowing by sternal accumulation.
*The need for111 In scintigraphy is very low if TEE is used.
*The need for111 In [[scintigraphy]] is very low if [[TEE]] is used.


'''MRI'''
'''[[MRI]]'''
*This is a good modality for helping delineate myocardial abscess. However, the portability and excellent resolution of echocardiography make it more practical than MRI.
*This is a good modality for helping delineate [[myocardial]] [[abscess]]. However, the portability and excellent resolution of [[echocardiography]] make it more practical than [[MRI]].


'''CT scan'''
'''[[CT scan]]'''
*Only anecdotal reports of diagnosis are available. It is not very sensitive.
*Only anecdotal reports of diagnosis are available. It is not very sensitive.


'''Intraoperative echocardiography'''
'''Intraoperative [[echocardiography]]'''
*Although invasive, small abscesses can be detected in the operating room by means of intraoperative echocardiography, which may enable the operating surgeon to drain the abscess effectively.
*Although invasive, small [[abscess]]es can be detected in the operating room by means of [[intraoperative]] [[echocardiography]], which may enable the operating [[surgeon]] to drain the [[abscess]] effectively.


==Other Diagnostic Studies==
==Other Diagnostic Studies==

Revision as of 19:37, 9 February 2020

Myocardial abscess
Myocardial abscess: Candida: Gross, natural color excellent depiction myocardial abscesses caused by Candida tropicalis. A 51yo man with acute monocytic leukemia.
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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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Syed Musadiq Ali M.B.B.S.[2]

overview

A cardiac abscess is a suppurative infection of the myocardium, endocardium, native or prosthetic valve tissue. Similar to other abscesses, it develops either by dissemination from a distant source such as bacteremia or sepsis or by direct extension of a pre-existing cardiac infective focus. Infective endocarditis has long been identified as the main cause of the latter. Although the incidence of cardiac abscesses continues to be investigated, it is presumably higher than noted postmortem and is of great importance when deciding the prognosis and management of patients. A single organism causes cardiac abscesses, usually Staphylococcus aureus or Escherichia coli. Less typically, polymicrobial abscesses have been noted. Important complications of a cardiac abscess, whether alone or with valve tissue, are conduction abnormalities on electrocardiogram (ECG). The incidence of perivalvular abscess among patients with infective endocarditis is between 30% to 40%, with the aortic valve having a higher predisposition than the mitral valve and annulus. Native aortic valve endocarditis, usually located in a weak part of the annulus near the atrioventricular node (AV), clearly demonstrates the anatomic predisposition and exemplifies why abscesses and heart block presents as frequent sequelae. Perivalvular abscesses are also more common with prosthetic valves. In this case, the annulus instead of the leaflet is usually the primary site of infection. The degree of conduction disruption, therefore, depends on the extent of the involvement of the conduction system and is more commonly seen in perivalvular aortic abscesses. Additionally, the severe extension of perivalvular infection can also result in extrinsic coronary compression, or disruption, leading to an acute coronary syndrome. Thus far, only aortic valve involvement and current IV drug use have been prospectively identified as independent risk factors for a perivalvular abscess. Any patient with a cardiac abscess, regardless of all other factors, has an increased risk of embolization, morbidity, and mortality. Prophylaxis remains a longstanding subject in the matter of prevention of IE or cardiac abscess. Thus far, prophylaxis is mostly based on observational studies and, in fact, places such as the United Kingdom no longer endorse antibiotic prophylaxis for dental procedures to prevent IE, the leading source of the cardiac abscess. One point against prophylaxis is the fact that tooth brushing has been proven to cause bacteremia and, therefore, makes it difficult to assess the rare versus high magnitude transient bacteremia and its effect on IE and its sequelae. For this reason, the United States and European countries have agreed that the use of prophylaxis is reserved only for those at "highest risk." On that same matter, the widespread use of antibiotics for the prevention and treatment of IE and abscesses could potentially create a setting where there will be an increased incidence of polymicrobial infection and antibiotic resistance, especially in immunocompromised patients.

Historical perspective

Pathophysiology

Myocardial abscess is a pus-containing infection of the endocardium, myocardium, prosthetic or native valves, perivalvular structures or the cardiac conduction system. [2] [3]

Pathogenesis

Post-mortem examination,of myocardial abscess, showed following pathological changes:

Macroscopic finding

  • The cardiac area was greatly enlarged, and when the pericardial sac was opened, it was found to contain 600 cc of partially clotted blood.
  • The parietal pericardium was blood tinged but smooth and glistening throughout [10] [11] [12] .
  • The epicardium was normal in appearance over the anterior aspect of the heart but glassy and coated with a thin layer of fibrinous exudate in the posterior aspect.
  • The tear involved the entire thickness of the myocardium so that a probe could be passed through it into the left ventricular cavity without resistance.
  • The surrounding myocardium was infiltrated by blood and flabby in consistence in an area about 6 cm in diameter.
  • Externally and on cut section this area displayed a variegated tinge from reddish brown to yellowish gray.
  • Clusters of honey-combed pockets, each pin head in size or larger, were scattered throughout this area.
  • Grossly, these pockets were suggestive of small abscesses and contained a thick, golden-yellow material.
  • The coronary arteries were diffusely narrowed, with atheroma formation and calcification.
  • The right coronary artery was occluded a short distance below its main stem by a firmly adherent, friable, yellowish-brown thrombotic mass.
  • Examination of the cardiac chambers revealed a laminated thrombus on the posterior aspect of the left ventricle[13].

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Microscopic finding

  • Myocardial infarct the microscopical sections showed an almost complete obliteration of the normal architecture[14] [15].
  • The muscle fibers displayed loss of striations and of nuclear patterns and seemed fused together into an amorphous mass of eosinophilic material.
  • The capillaries in the area were congested, and extravasated red cells were present throughout.
  • There was a concomitant marked infiltration of polymorphonuclear leukocytes either scattered or in clusters, and this extended into the epicardium.
  • The leukocytes were not well preserved; the majority were fused together or showed karyorrhexis and karyolysis resulting in a scattering of cellular débris.
  • The endocardial mural thrombus consisted of amorphous eosinophilic material and was interspersed with white cells and cellular débris.
  • The mural thrombus merged indistinctly into the adjacent necrotic myocardium.
  • The thrombotic mass in the lumen of the right coronary artery showed incipient organization with intimal histiocytic and fibroblastic proliferation and atheromatous changes[16].

Causes

Endocarditis

Bacteremia

Myocardial infarction

Other settings associated with myocardial abscesses that have been reported in the literature include the following:

Differential Diagnosis

Myocardial Abscess should be differentiated from other diseases presenting with fever, chest pain and anorxia. The differentials include the following:[24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Pulmonary embolism
  • On CT angiography:
    • Intra-luminal filling defect
  • On MRI:
    • Narrowing of involved vessel
    • No contrast seen distal to obstruction
    • Polo-mint sign (partial filling defect surrounded by contrast)
✔ (Low grade) ✔ (In case of massive PE) - - - -
Infective Endocarditis
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
- - - - - -
Non-Bacterial Thrombotic Endocarditis
  • ST elevation
  • PR depression
✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Libman Sack Endocarditis - - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

-
Fever of unknown origin (FUO) - - - - - -

Epidemiology and Demographics

Risk Factors

Any septic focus can theoretically lead to myocardial abscess. These are the primary foci in order of frequency of causing myocardial abscess.

Spread from the urinary tract is the most common cause.
Spread from the gastrointestinal tract is the second common cause (e.g. perforated appendix, perforated colon cancer, diverticulitis ,and cohn’s disease.)
e.g. pott's disease or osteomyelitis
  • Hematogenous spread:
From distant septic foci.
Following chest abdominal or pelvic surgery.

Any condition compromising the immune system is a risk factor for developing myocardial abscess. The following were the risk factors in observed patients. [45]

Screening

According to the USPSTF, screening for retroperitoneal abscess is not recommended.

Natural History, Complications and Prognosis:

Natural history

If left untreated, myocardial abscess may cause heart block, septal rupture with very high incidence of morbidity and mortality.

Complications :

The following are potential complications of myocardial abscess:

Prognosis

Diagnosis

History

Symptoms

One must bear in mind certain constellations of symptoms that may raise the suggestion of myocardial abscess. For example, fever is the most common symptom, presenting in 80%-85% of patients. It is absent in some patients who are elderly; those who have CHF, severe debility, or chronic renal failure; and in patients with coagulase-negative staphylococcal infection and abscess. Another characteristic symptom is chills, which occurs in 42%-75% of cases.

Common symptoms:

Less common symptoms:

Physical Exam

General Appearance

Physical examination findings commonly encountered in myocardial abscess are mainly due to the underlying infective endocarditis. These include the following: Fever, Tachycardia, Murmur, especially changing or new murmur, Neurological abnormalities, Embolic event, Splenomegaly, Clubbing, Peripheral manifestations,Osler nodes, Splinter hemorrhages, Petechiae, Janeway lesions, Retinal lesions (Roth spots),Widening pulse pressure, especially with involvement of the aortic valve and progression of aortic regurgitation The patient is usually fatigued & looking ill due to the preexisting risk factor. In advanced cases with septicemia, the patient may be drowsy with decreased level of consciousness.[45]

Vital signs

Chest Examination

Lab Findings

Radiological Findings

Chest radiography

Transthoracic echocardiography

  • TTE helps evaluate patients in whom endocarditis or myocardial abscess is suggested clinically. Findings frequently allow the morphologic confirmation of infection and increasingly aid in making decisions regarding management.
  • One must perform an echocardiographic evaluation in all patients suspected of having an intracardiac or pericardial infection, including those with negative blood culture findings.
  • TTE has a sensitivity of 23% and specificity of 98.6%.
  • According to Ellis et al (1985), the following 5 criteria are 86% sensitive and 88% specific for myocardial abscess:
  • Walker et al report a rare case of a myocardial abscess in valvular endocarditis that was difficult to assess with 2-dimensional TTE; however, real-time 3-dimensional contrast TTE allowed visualization of the full extent of the defect and its precise anatomical location, prior to successful surgical resection.

Transesophageal echocardiography

Scintigraphy

MRI

CT scan

  • Only anecdotal reports of diagnosis are available. It is not very sensitive.

Intraoperative echocardiography

Other Diagnostic Studies

Electrocardiography

  • New-onset and persistent electrocardiographic conduction abnormalities may be observed. Gradual PR prolongation may be observed, and it may suggest development of valve ring abscess.
  • Although not a sensitive indicator of perivalvular infection or abscess (28%), these findings are relatively specific (85-90%). See the image below.

Tests of immune system stimulation

  • Tests results may show disease activity, but the tests are costly and not very efficient for diagnosis or monitoring response to therapy
  • These may include testing of circulating immune complexes, rheumatoid factor, quantitative immune globulin, cryoglobulins, and C-reactive protein.

Serologic tests

  • Serological test findings are used to evaluate cardiac sepsis in which blood culture findings are negative.
  • Tests to detect antibodies to ribitol teichoic acids from staphylococci may help distinguish uncomplicated S aureus bacteremia from that associated with cardiac involvement.
  • These tests have not been used in clinical applications because of their lack of adequate specificity or predictive value.

Procedures

  • Cardiac catheterization may add very little to the imaging studies and is not recommended unless coronary angiography is needed for patients undergoing valve surgery who also may have significant coronary artery disease.

Treatment

Medical treatment

  • Intravenous antibiotics should be administered in a timely fashion once a patient is suspected of IE or a cardiac abscess. Empiric broad-spectrum antibiotics until further characterization of infective species should be monitored for at least 6 weeks of therapy in this patient population.
  • Supportive treatment includes the following:
    • Fluid and electrolyte balance
    • Nutritional support

Surgical Treatment

  • Surgery consult and the time of surgical intervention is of high importance when approaching a patient with a cardiac abscess.
  • There is increased morbidity and mortality in patients in whom surgery is delayed. Thus early surgery is recommended. Surgery for these patients aims toward the eradication of the infection and correction of hemodynamic abnormalities.
  • However, some patients with periannular extension of infection or myocardial abscess could potentially be treated without surgical intervention. These patients include:
    • Patients with smaller (less than 1 cm) abscesses
    • Patients who do not have complications of heart block, an echocardiographic progression of abscess during antibiotic therapy
    • Patients who do not have valvular dehiscence or insufficiency
  • It is recommended that patients who do not undergo surgery are monitored closely with serial TEE repeated at 2, 4, and 8 weeks after completion of antibiotic therapy.

References

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  9. Saphir O: Myocarditis: A general review, with an analysis of two hundred and forty cases. Arch Pathol 32,1000-1051 (1941)
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