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

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. 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. 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. 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. 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. RNA
viruses
Picornaviruses
Togaviruses
FlavivirusesParamyxoviruses
Orthomyxovirus
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Coxsackie A + BEchovirus
PoliovirusHepatitis virus
Influenza
Respiratory Syncitial virus
Mumps
Rubella
Dengue Fever
Yellow Fever

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. 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. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 9
http://eurheartj.oxfordjournals.org

10. 2/3/2015Acute myocarditis Prof. Dr . Saad S Al Ani Khorfakkan Hospital 10
http://eurheartj.oxfordjournals.org

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. • 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. 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. 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. 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. 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. 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.
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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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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.
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