This document discusses myocarditis, including its definition, etiology, clinical features, diagnosis, treatment, prognosis, and complications. Myocarditis is defined as inflammation of the heart muscle, which can be caused by various viral and bacterial infections. Clinical features include fever, chest pain, and heart failure symptoms. Diagnosis involves electrocardiograms, cardiac imaging like echocardiograms and MRI, and endomyocardial biopsy. Treatment is supportive with medications, while prognosis depends on the age of onset, with higher mortality in newborns and potential for recovery of heart function in older children and adults.

1. Dr M.Sanjeevappa
M.D.(paeds)
Asst.Professor
Dept of Paediatrics GMC ,ATP.

2. Objectives:
 Definition
 Etiology
 Epidemiology
 Clinical features
 Diagnosis
 Treatment
 Prognosis and complications
 Prevention

3. IE defined as an infection of the
endocardial surface of the heart ,which may
include one or more heart valves, the mural
endocardium, or a septal defect.
Its intra cardiac effects include severe
valvular insufficiency ,which may lead to
congestive heart failure and myocardial
abscesses.

5. COMMON UNCOMMON
NATIVE VALVE OR OTHER CARDIAC LESIONS
 Streptococcus viridans
 Staphylococcus aureus
 Group D streptococcus
PROSTHETIC VALVE
 Staphylococcus epidermidis
 Staphylococcus aureus
 Viridans group streptococcus
 Pseudomonas aeruginosa
 Serratia marcescens
 Diphtheroids
 Legionella species*
 HACEK group
 Fungi
NATIVE VALVE OR OTHER CARDIAC LESIONS
 Streptococcus pneumoniae
 Haemophilus influenzae
 Coagulase-negative
staphylococci
 Abiotrophia defectiva
 Coxiella burnetii (Q fever)
 Neisseria gonorrhoeae
 Brucella
 Chlamydia psittaci
 Chlamydia trachomatis
 Chlamydia pneumoniae
 Legionella
 Bartonella
 Tropheryma whipplei
 HACEK group
 Streptobacillus moniliformis
 Pasteurella multocida
 Campylobacter fetus

6.  Often a complication of congenital or rheumatic heart disease.
 1.7 and 1.2 per 100,000 male and female children younger than 10
years respectively.
High risk group :
 Unrepaired cyanotic congenital heart disease.
 Prosthetic cardiac valves or prosthetic material used for cardiac valve
repair.
 Completely repaired defects with prosthetic material or device.
 Repaired congenital heart disease with residual defects.
 permanent valve disease from rheumatic fever , previous infective
endocarditis.
NEITHER SECUNDUM ASD NOR PDA OR PULMONIC STENOSIS
AFTER REPAIR IS ASSOCIATED WITH IE.

7. HISTORY:
 Prior congenital or rheumatic heart disease.
 Preceding dental, urinary tract, or intestinal
procedure.
 Intravenous drug use.
 Central venous catheter.
 Prosthetic heart valve.

8.  infectious process on the valves:
perivalvular abscess, incompetent valve,
conduction disturbances ,congestive heart failure.
 vascular phenomena:
septic pulmonary or arterial emboli,
mycotic aneurysm, intracranial hemorrhage .
 bacteremic seeding of remote sites :
osteomyelitis, psoas or peri renal abscess
 immunologic phenomena:
glomerulonephritis, Osler’s nodes, Roth’s spots, positive
rheumatoid factor, antinuclear antibodies.

9. SYMPTOMS:
 Fever
 Chest and abdominal pain
 Arthralgia, myalgia
 Dyspnea
 Weight loss
 CNS manifestations (stroke, seizures, headache)

10. SIGNS:
 Tachycardia.
 Embolic phenomena.
 Janeway lesions.
 New or changing murmur.
 Splenomegaly.
 Arthritis.
 Heart failure.
 Metastatic infection.
 Clubbing.

16.  Blood culture: 3 to 5 samples to be taken with in 24 hrs
 Echocardiography:valve vegetations, prosthetic valve
dysfunction or leak, myocardial abscess, new-onset valve
Insufficiency
 CXR: bilateral infiltrates, pleural effusions
 Elevated erythrocyte sedimentation rate
 Elevated C-reactive protein
 Anemia
 Leukocytosis
 Hypocomplementemia
 Rheumatoid factor
 Hematuria

17. Major criteria:
 Positive blood cultures.
 Evidence of endocarditis on echocardiography.
Minor criteria:
 Predisposing conditions, fever, embolic-vascular signs.
 Immune complex phenomena (glomerulonephritis,
arthritis , janeway lesions)
 A single, positive blood culture or serologic evidence of
infection.
 Echocardiographic signs not meeting the major criteria.

18.  Definite IE
◦ Micro organism isolation in a valvular vegetation, embolized
vegetation, or intra cardiac abscess (via culture or histology)
◦ Histologic evidence of vegetation or intracardiac abscess
 Possible IE
◦ 2 major
◦ 1 major and 3 minor
◦ 5 minor
 Rejected IE
◦ Resolution of illness with in four days or less of antibiotics

19. REGIMRN DOSAGE & ROUTE DURATION
Aqueous crystalline
penicillin G sodium
200,000 U/kg per 24 hr IV in
4-6 equally divided doses
4 weeks
or
Ceftriaxone sodium
100 mg/kg per 24 hr
IV/IM in 1 dose
4 weeks
or
Ceftriaxone sodium
plus
Gentamicin sulfate
100 mg/kg per 24 hr
IV/IM in 1 dose
3 mg/kg per 24 hr IV/IM in 1
dose,
or 3 equally divided doses
2weeks
2weeks
or
Vancomycin
hydrochloride
40 mg/kg per 24 hr
IV in 2-3 equally divided doses
4weeks

20. REGIMRN DOSAGE & ROUTE DURATION
OXACILLIN-SUSCEPTIBLE
STRAINS
Nafcillin or oxacillin
with
gentamicin sulfate
Nafcillin or oxacillin
200 mg/kg per 24 hr IV in 4-6
equally divided doses
3 mg/kg per 24 hr IV/IM in 3
equally divided doses
6 Weeks
3-5 days
For penicillin-allergic
patients:
Cefazolin
with
gentamicin sulfate
cefazolin 100 mg/kg per
24 hr IV in 3 equally divided doses.
3 mg/kg per 24 hr IV/IM in 3
equally divided doses
6 Weeks
3-5 days
OXACILLIN-RESISTANT
STRAINS
Vancomycin
40 mg/kg per 24 hr
IV in 2-3 equally divided doses
6weeks

21.  mortality remains high- 20-25%.
 morbidity - 50-60%
COMPLICATIONS:
 heart failure.
 Myocardial abscesses.
 Pulmonary emboli.
 mycotic aneurysms.
 rupture of a sinus of Valsalva.
 obstruction of a valve.
 heart block.
 Meningitis.
 Osteomyelitis.
 Arthritis.
 renal abscess.
 Purulent pericarditis.
 immune complex-mediated glomerulonephritis.

22.  Prosthetic cardiac valve or prosthetic material
used for cardiac valve repair.
 Previous infective endocarditis.
CONGENITAL HEART DISEASE (CHD)
 Unrepaired cyanotic CHD, including palliative shunts
and conduits.
 Completely repaired CHD with prosthetic material or
device.
 Repaired CHD with residual defects at the site or
adjacent to the site of a prosthetic patch, or prosthetic
device.
 Cardiac transplantation recipients who develop
cardiac valvulopathy.

23. Oral medication Amoxicillin 50 mg/kg
Unable to take oral
medication
Ampicillin
or
Cefazolin
or
ceftriaxone
50 mg/kg IM or IV
50 mg/kg IM or IV
50 mg/kg IM or IV
Allergic to penicillins or
ampicillin—oral
Cephalexin
or
Clindamycin
or
Azithromycin or
clarithromycin
50 mg/kg
20 mg/kg
15 mg/kg
Allergic to penicillins or
ampicillin and unable to
take oral medication
Cefazolin
Or
ceftriaxone
or
clindamycin
50 mg/kg IM or IV
50 mg/kg IM or IV
20 mg/kg IM or IV

24. Objectives:
 Definition
 Etiology
 Clinical features
 Diagnosis
 Treatment
 Prognosis and complications
 Prevention

25.  Myocarditis is defined as inflammation of the
heart muscle.
 Characterized by inflammatory cell infiltrates,
myocyte necrosis, or myocyte degeneration.

26. Viral Infections:
 Enteroviruses - Coxsackievirus
 adenovirus,
 parvovirus,
 Epstein-Barr virus,
 influenza virus,
 cytomegalovirus
 hepatitis C virus
Bacterial Infections:
 Diphtheritic myocarditis
Other infections:
 rickettsia, protozoa, parasitic infections, fungal
infections

27. Injury and innate immune response
Virus or toxin Initial myocyte injury
from pathogen or toxin
Decreased regulatory T-cell function,
activation of cytolytic T cells,
and increased Th1 and Th2 cytokines
Acquired immune response
Antigen-presenting cells stimulate
pathogen-specific T-cell response
Antibodies to pathogens may
cross-react with endogenous epitopes
(e.g., cardiac myosin and -adrenergic receptor)
Epitope spreading between
endogenous myocardial epitopes
Recovery or persistent cardiomyopathy
Viral clearance and Ongoing injury with persistent viral infection
or immune response
down-regulation of immune response
Myocyte cell death from direct
viral damage, cytolytic T cells, or
apoptosis
Exposure of innate immune
system to pathogens and
intracellular sequestered
APC
Regulatory T cell

28. Infants and young children:
 Fever.
 Respiratory distress.
 Tachycardia.
 Hypotension.
 Gallop rhythm, and cardiac murmur.
acute or chronic myocarditis:
 chest discomfort.
 Fever.
 Palpitations.
 easy fatigability.
 syncope/near syncope.

29. On examination:
 Hyperactive precordial impulse.
 Gallop rhythm.
 Apical systolic murmur of mitral insufficiency.
 Hepatic enlargement
 Peripheral edema.
 Pulmonary findings such as wheezes or rales.

30. Electrocardiographic changes:
 Sinus tachycardia,
 Atrial or ventricular arrhythmias, heart block,
 Diminished QRS voltages
Chest x-ray:
 Cardiomegaly,
 Pulmonary vascular prominence or pulmonary edema.
 Pleural effusions.
Echocardiography:
 Diminished ventricular systolic function,
 Cardiac chamber enlargement,
 Mitral insufficiency,
 Pericardial infusion.

31. Cardiac MRI :
 Presence and extent of edema,
 Gadolinium-enhanced hyperemic capillary leak.
 Myocyte necrosis.
 Left ventricular dysfunction.
Endomyocardial biopsy:
 Inflammatory cell infiltrates.
 Myocyte damage.
 Performing molecular viral analysis using PCR.
Nonspecific tests:
 ESR
 CPK levels.
 Cardiac troponin I, and brain natriuretic peptide levels.

32. Supportive care :
 Inotropic agents : milrinone, dobutamine.
 Diuretics .
 Mechanical ventilatory support.
 Antiarrhythmic agents : amiodarone.
Intravenous immune globulin.
corticosteroids have been reported to improve cardiac
function.

33.  prognosis in newborns is poor-75%mortality.
 prognosis is better for children and adolescents.
 DCM -cardiac transplantation.
 Recovery of ventricular function -10-50% of patients.