Myocarditis

Dr P Mayurathan
Consultant Physician (Act)
 Myocarditis
• Disease marked by inflammation and damage of the cardiac muscle
(inflammatory cardiomyopathy)

• Defined as an inflammatory infiltrate of the myocardium with necrosis and/or

degeneration of adjacent myocytes

• Usually affects otherwise healthy individuals

• 5 – 20% of SCD in young adults are due to myocarditis

• Major long term complications are chronic heart failure and dilated
cardiomyopathy
 Causes of Myocarditis
• Viral – Enterovirus, coxsackie B, adenovirus, influenza, CMV, poliomyelitis, EBV, HIV-1, viral
hepatitis, mumps, rubeola, varicella, arbovirus, respiratory syncytial virus, HSV, yellow
fever virus, rabies, parvovirus, dengue virus

• Rickettsial - Scrub typhus, Rocky Mountain spotted fever, Q fever

• Bacterial - Diphtheria, tuberculosis, streptococci, meningococci, brucellosis, clostridia,

staphylococci, melioidosis, Mycoplasma pneumoniae, psittacosis

• Spirochetal - Syphilis, leptospirosis/Weil disease, relapsing fever/Borrelia, Lyme disease

• Fungal - Candidiasis, aspergillosis, cryptococcosis, histoplasmosis, actinomycosis,

blastomycosis, coccidioidomycosis, mucormycosis

• Protozoal - Chagas disease, toxoplasmosis, trypanosomiasis, malaria, leishmaniasis,

balantidiasis, sarcosporidiosis

• Helminthic - Trichinosis, echinococcosis, schistosomiasis, heterophyiasis, cysticercosis,

visceral larva migrans, filariasis
 Causes of Myocarditis
• Chemotherapeutic drugs - Doxorubicin and anthracyclines, streptomycin,
cyclophosphamide, interleukin-2, anti-HER-2 receptor antibody/Herceptin

• Antibiotics - Penicillin, chloramphenicol, sulfonamides

• Antihypertensive drugs - Methyldopa, spironolactone

• Antiseizure drugs - Phenytoin, carbamazepine

• Amphetamines, cocaine, catecholamines

• Chemicals - Hydrocarbons, carbon monoxide, arsenic, lead, phosphorus,

mercury, cobalt

• Physical agents - Radiation, Heatstroke, Hypothermia

 Causes of Myocarditis
• Bites/stings - Scorpion venom, snake venom, black widow spider venom,
wasp venom, tick paralysis

• Acute rheumatic fever

• Systemic inflammatory disease - Giant cell myocarditis, sarcoidosis,

Kawasaki disease, Crohn disease, SLE, ulcerative colitis, Wegener
granulomatosis, thyrotoxicosis, scleroderma, rheumatoid arthritis

• Peripartum cardiomyopathy

• Post-transplant cellular rejection

 Myocarditis – Morphology of Heart
• These are non-specific and include
normal or dilated chambers

• Softening and pallor of the ventricles

may be present

• Concomitant pericardial effusion and

pericarditis may be present in cases of
viral or bacterial myocarditis

• Late stages of myocarditis may show

fibrosis that can be either focal or
diffuse, but the distribution is often
random
 Myocarditis - Pathogenesis
• An inflammatory response within the myocardium

• The presence of myocyte necrosis is required for certain types of myocarditis —

specifically, lymphocytic myocarditis that is triggered by viruses and augmented
by autoimmunity

• The myocyte damage is believed to be mediated both by direct invasion of the

myocardium and by immune insult

• In general, the histologic patterns can be divided into the following categories:
– Lymphocytic (including viral and autoimmune forms)
– Eosinophilic (of which hypersensitivity myocarditis is the most common
type, followed by hypereosinophilic syndrome)
– Granulomatous (cardiac sarcoidosis and giant-cell myocarditis)
– Neutrophilic (bacterial, fungal, and early forms of viral myocarditis)
– Reperfusion type/contraction band necrosis (present in catecholamine-
induced injury and reperfusion injury)
 Myocarditis – Clinical Features
• Mild symptoms of chest pain, fever, sweats, chills, dyspnea

• In viral myocarditis: Recent history (≤1-2 wk) of flulike symptoms of

fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper
respiratory tract infection

• Palpitations, syncope, or sudden cardiac death due to underlying

ventricular arrhythmias or atrioventricular block (especially in giant cell
myocarditis)

• Heart failure
 Myocarditis – Investigations
• FBC

• ESR/CRP

• Cardiac enzymes – Troponin, CPK

• ECG – Non-specific ST and T-wave changes

• Echocardiography: To exclude other causes of heart failure and to evaluate the degree of
cardiac dysfunction

• Cardiac angiography: To rule out coronary ischemia

• Gadolinium-enhanced MRI: To assess extent of inflammation and cellular edema; nonspecific

• Serum viral antibody titers

• Viral genome testing in endomyocardial biopsy

• Rheumatologic screening
 Myocarditis - Management
• Supportive care:
– Hemodynamic and cardiac monitoring
– Administration of supplemental oxygen
– Fluid management

• Management of heart failure

• May need antiarrhythmic agents and inotropes

• Invasive treatment:
– Temporary pace maker if complete heart block
– Ventricular assist device or percutaneous circulatory support; left
ventricular assistive devices (LVADs) and extracorporeal membrane
oxygenation
– Cardiac transplantation
Pericarditis
 Pericardium and Pericardial Space
• Pericardium act as a protective covering for the heart

• 2 layers:
– Outer fibrous pericardial sac (parietal pericardial layer)
– Inner serous pericardium (visceral pericardial layer)

• Inner layer lines the heart and great vessels and its reflection the outer parietal
pericardium

• Normal amount of pericardial fluid is 20 – 49 ml

• The pericardial fluid lubricates the surface of the heart

 Acute Pericarditis
• Acute pericarditis is an inflammation
of the pericardium characterized by
chest pain, pericardial friction rub, and
serial ECG changes.

• Classically fibrinous material is

deposited into the pericardial space
and pericardial effusion often occurs
 Causes of Pericarditis
• Idiopathic

• Infectious conditions - viral, bacterial, tuberculous infections, fungal

pericarditis

• Inflammatory disorders - RA, SLE, scleroderma, rheumatic fever

• Metabolic disorders - renal failure, hypothyroidism, hypercholesterolemia

• Cardiovascular disorders - acute MI, Dressler’s syndrome, aortic dissection

• Miscellaneous - iatrogenic, neoplasms, drugs, irradiation, cardiovascular

procedures, trauma
 Pericarditis - Pathogenesis
• In most cases of acute pericarditis, the pericardium is acutely inflamed
and has an infiltration of polymorphonuclear (PMN) leukocytes and
pericardial vascularization

• Often, the pericardium manifests a fibrinous reaction with exudates and

adhesions

• The pericardium may develop a serous or hemorrhagic effusion

• A granulomatous pericarditis occurs with tuberculosis, fungal infections,

RA and sarcoidosis

• Uremic pericarditis is thought to result from inflammation of the visceral

and parietal layers of the pericardium by metabolic toxins that
accumulate in the body owing to kidney failure
 Pericarditis – Morphology of Heart
• Pericardium is thickened

• There may be exudates and adhesions

• The pericardium may develop a serous or hemorrhagic effusion

• There may be granuloma formations

 Pericarditis – Clinical Features
• Chest pain is the cardinal symptom of pericarditis

• It is sharp central chest pain exacerbated by deep inspiration, movement

and lying down

• Typically relieved by sitting forward

• Common associated signs and symptoms include low-grade intermittent

fever, dyspnea/tachypnea, cough, and dysphagia

• Pericardial rub

• In tuberculous pericarditis, fever, night sweats, and weight loss are

commonly noted (80%).
 Pericarditis – Investigations
• ECG - typically shows concave-upwards ST-elevation and PR-depression in
all leads with reciprocal ST-depression and PR-elevation in aVR and V1
• Echocardiography
• CXR
• FBC

• ESR/CRP
• Cardiac enzymes
• Renal functions
 Pericarditis - Management
• Treatment for underlying cause

• For patients with idiopathic or viral pericarditis, therapy is directed at symptom

relief

• Pharmacologic treatment
– NSAIDs are the mainstay of treatment. The treatment should last 7-14 days
– Colchicine, alone or in combination with an NSAID, can be considered for
patients with recurrent or continued symptoms beyond 14 days
– Corticosteroids should not be used for initial treatment of pericarditis unless
it is indicated for known immune disease, the patient’s condition has no
response to NSAIDs or colchicine, or both agents are contraindicated

• Surgical treatment
– Surgical procedures include pericardiectomy, pericardiocentesis, pericardial
window placement, and pericardiotomy
Post-Myocardial Infarction Pericarditis
• Occurs about 20%
• Usually first few days following MI
• More common in anterior STEMI with high serum cardiac enzymes
• Incidenced is reduced to 5-6% with thrombolysis
• Difficult to differentiate this pain from angina
• Good history and serial ECGs are helpful

Dressler’s Syndrome
• During the recovery phase of MI – late onset
• Usually 2 – 10 weeks post infarction
• Due to autoimmune reaction
• Anti-myocardial antibodies can often be found
• Recurrences are common
• DD – New MI, Unstable angina
 Constrictive Pericarditis
• Chronic process and will not cause immediately life threatening

• The pericardium become thick, fibrous and calcified (TB commonly causes
pericardial calcification)

• Therefore the pericardium become inelastic and interfere with diastolic filling of the
heart

• This is known as constrictive pericarditis

• Later the subepicardial layers of myocardium may undergo fibrosis, atrophy and
calcification

• Causes – TB, haemopericardium, bacterial infection, rheumatic heart disease, open

heart surgery, dopamine agonists (eg.Cabergoline, pergolide)

• DD – Restrictive cardiomyopathy
 Constrictive Pericarditis - Clinical Features

• Chest pain and SOB, orthopnoea, PND – Not very common

• Fatigue and dependent oedema

• Rarely atrial fibrillation

• Hypotension, pulsus paradoxus

• Elevated JVP, Kussmaul’s sign

• Pericardial knock, Features of pulmonary oedema

• Hepatomegaly, Ascites
 Constrictive Pericarditis - Investigations
• CXR
– Normal or slightly small size heart
– Pericardial calcification

• ECG – low voltage complexes with generalized t-wave flattening or

inversion

• Echo

• CT/MRI

• Eodomyocardial biopsy

• Cardiac catheterization
 Constrictive Pericarditis - Management

• It is a treatable condition

• Complete resection of pericardium

 Pericardial Effusion
• Collection of fluid within the pericardial space

• Common with acute pericarditis

• Causes globular heart in CXR

Cardiac Tamponade
• Large amount of fluid collection in the pericardial space causing

compromised ventricular filling and haemodynamic unstability