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Acute viral myocarditis

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Definition ,causes ,pathophysiology ,presentations ,diagnosis,differential diagnosis,Management ,prognosis,

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Acute viral myocarditis

  1. 1. Acute Viral Myocarditis Prof. Dr. Saad S al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital ,Sharjah ,UAE saadsalani@yahoo.com
  2. 2. 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
  3. 3. 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
  4. 4. Causes 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 4 Viral Infections are the most common etiology though myocardial toxins ,drug exposures ,hypersensitivity reactions ,and immune disorders
  5. 5. Causes (cont.) Coxsackievirus and other enteroviruses, adenovirus, parvovirus, Epstein-Barr virus, and cytomegalovirus are the most common causative agents in children 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 5
  6. 6. RNA viruses Picornaviruses Togaviruses FlavivirusesParamyxoviruses Orthomyxovirus 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 6 Coxsackie A + BEchovirus PoliovirusHepatitis virus Influenza Respiratory Syncitial virus Mumps Rubella Dengue Fever Yellow Fever
  7. 7. DNA viruses Adenovirus Retrovirus Herpesviruses Erythrovirus 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 7 A 1, 2 ,3, and 5 1 (B19V) and 2 Human herpes virus 6 A/B Cytomegalovirus HIV Epstein-Barr virus Varicella-zoster virus
  8. 8. Epidemiology Manifestations 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 8
  9. 9. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 9 http://eurheartj.oxfordjournals.org
  10. 10. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 10 http://eurheartj.oxfordjournals.org
  11. 11. Clinical Manifestations Sudden death Acute cardiogenic shock Asymptomatic or nonspecific generalized illness 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 11
  12. 12. • Children with myocarditis present with symptoms that can be mistaken for other types of illnesses; respiratory presentations were most common. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 12
  13. 13. Clinical Manifestations (cont.) Infants and young children Fulminant presentation Fever, Respiratory distress, Tachycardia, Hypotension, Gallop rhythm, and Cardiac murmur Associated findings may include a rash or evidence of end organ involvement such as hepatitis or aseptic meningitis 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 13
  14. 14. Clinical Manifestations (cont.) Patients with acute or chronic myocarditis Presentation: Chest discomfort, Fever, Palpitations, Easy fatigability, or Syncope/Near syncope 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 14
  15. 15. Clinical Manifestations (cont.) Cardiac findings Overactive precordial impulse, Gallop rhythm, and Apical systolic murmur of mitral insufficiency In patients with associated pericardial disease, a rub may be noted 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 15
  16. 16. Clinical Manifestations (cont.) Patient with decompensated congestive heart failure -Hepatic enlargement -Peripheral edema -Pulmonary findings such as wheezes or rales 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 16
  17. 17. 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 17
  18. 18. Diagnosis (cont.) • Chest roentgenograms In severe, symptomatic cases reveal: 1. Cardiomegaly 2. Pulmonary vascular prominence 3. Overt pulmonary edema 4. Pleural effusions. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 18
  19. 19. Diagnosis(cont.) • Echocardiography Often shows: 1. Diminished ventricular systolic function 2. Cardiac chamber enlargement 3. Mitral insufficiency 4. Pericardial infusion (occasionally) 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 19
  20. 20. Diagnosis(cont.) • Endomyocardial biopsy May be useful in identifying inflammatory cell infiltrates or myocyte damage • Molecular viral analysis using polymerase chain reaction (PCR) techniques. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 20
  21. 21. 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 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 21
  22. 22. Diagnosis(cont.) • Supportive but nonspecific tests include 1. Sedimentation rate 2. CPK isoenzymes 3. Cardiac troponin I 4. Brain natriuretic peptide (BNP) levels 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 22
  23. 23. Differential diagnosis * Carnitine deficiency * Other metabolic disorders of energy generation *Hereditary mitochondrial defects *Idiopathic dilated cardiomyopathy *Pericarditis *Anomalies of the coronary arteries 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 23
  24. 24. 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 24
  25. 25. Management (cont.) • In extremis, mechanical ventilatory support and 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 25
  26. 26. 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 26
  27. 27. Management(cont.) Significant atrial or ventricular arrhythmias: • Specific antiarrhythmic agents ( amiodarone) should be administered and ICD placement considered. • Immunomodulation is controversial. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 27
  28. 28. Management(cont.) • Intravenous immune globulin may have a role in the treatment of acute or fulminant myocarditis • Corticosteroids ? 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 28
  29. 29. Management(cont.) • Relapse has been noted in patients receiving immunosuppression • Specific antiviral therapies ? 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 29
  30. 30. 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 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 30
  31. 31. 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 31
  32. 32. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 32

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