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Myocarditis

Aka: Myocarditis, Viral Myocarditis, Postinfectious Myocarditis, Dilated Cardiomyopathy Secondary to Viral Myocarditis, Viral Carditis

I. Causes

  1. See Cardiomyopathy Causes
  2. Idiopathic
  3. Lymphocytic or immunologic
  4. Medications
    1. Chemotherapy
    2. Clozapine (and other Antipsychotics)
  5. Alcohol Abuse
  6. Carbon Monoxide
  7. Acute infectious (follows Upper Respiratory Infection)
    1. Bacterial illness
      1. Streptococcal Pharyngitis (with secondary Acute Rheumatic Fever)
      2. Lyme Disease (strongly consider in endemic areas)
      3. Diphtheria (toxin related)
    2. Viral illness
      1. Parvovirus B19 (most common in U.S. now)
      2. Coxsackie Virus B (previously most common in U.S.)
      3. Influenza
      4. Hepatitis
      5. Adenovirus
      6. HIV Infection
      7. Cytomegalovirus (CMV)
    3. Tropical Disease
      1. Trypanosoma cruzi (Chagas' Disease, most common cause worldwide)

II. Associated Conditions

  1. Pericarditis

III. Symptoms

  1. Presentations vary widely
    1. Most cases are mild and asymptomatic
    2. However, can be severe and life-threatening (especially in children)
      1. May be responsible for up to 20% of unexplained cardiac death in young adults
  2. Influenza-like illness presentation is common
    1. Fever (Viral Myocarditis)
    2. Fatigue
    3. Myalgias
    4. Arthralgias
    5. Malaise
  3. Chest symptoms
    1. Palpitations
    2. Chest Pain
    3. Sinus Tachycardia out of proportion to other findings (or other dysrhythmia)
  4. Symptoms related to secondary events and decompensation
    1. Myocardial Infarction
    2. Congestive Heart Failure
  5. Infant presentation
    1. Poor feeding
    2. Lethargy

IV. Signs

  1. Pericardial Friction Rub
  2. Loud S3 Gallop
  3. Sinus Tachycardia (or other fast dysrhythmia)
    1. Out of proportion to other causes (e.g. beyond what would be expected with fever alone)
  4. Weak pulses

V. Labs

  1. Troponin I increased
  2. Creatine Phosphokinase (CPK) increased
  3. Acute phase reactants
    1. Erythrocyte Sedimentation Rate (ESR) >60 mm/h
    2. C-Reactive Protein (CRP) increased
    3. Leukocytosis

VI. Imaging

  1. Electrocardiogram
    1. Diffuse EKG changes (all leads)
    2. Saddle-shaped ST segment elevation progresses to T Wave inversion
    3. Normalizes in 2 months
  2. Chest XRay
    1. Cardiomegaly in 50% cases
  3. Echocardiogram
  4. Cardiac MRI
    1. Most accurate non-invasive imaging modality to diagnose Myocarditis

VII. Differential Diagnosis

  1. See Congestive Heart Failure
  2. See Acute Coronary Syndrome

VIII. Management

  1. Disposition is based on severity of clinical presentation
    1. Initial inpatient management is waranted in severe cases
  2. Management is typically symptomatic
  3. Specific management may be based on underlying cause (e.g. Lyme Disease)
  4. Various agents have been used historically, especially for Viral Myocarditis (e.g. coxsachievirus)
    1. IV Ig
    2. Corticosteroids
    3. Cyclosporine

IX. References

  1. Sharrief in Majoewsky (2012) EM:Rap 12(5): 8
  2. Klauer (2013) Congestive Heart Failure and Myocarditis, EM Bootcamp, CEME

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Ontology: Myocarditis (C0027059)

Definition (CHV) inflammation of the heart muscle
Definition (NCI) Inflammation of the muscle tissue of the heart.
Definition (NCI_CTCAE) A disorder characterized by inflammation of the muscle tissue of the heart.
Definition (MSH) Inflammatory processes of the muscular walls of the heart (MYOCARDIUM) which result in injury to the cardiac muscle cells (MYOCYTES, CARDIAC). Manifestations range from subclinical to sudden death (DEATH, SUDDEN). Myocarditis in association with cardiac dysfunction is classified as inflammatory CARDIOMYOPATHY usually caused by INFECTION, autoimmune diseases, or responses to toxic substances. Myocarditis is also a common cause of DILATED CARDIOMYOPATHY and other cardiomyopathies.
Definition (CSP) inflammation of the muscular walls of the heart.
Concepts Disease or Syndrome (T047)
MSH D009205
ICD9 429.0
ICD10 I51.4
SnomedCT 155380004, 251060004, 195119007, 50920009
English Myocarditides, Myocarditis NOS, Myocarditis, unspecified, Myocarditis, myocarditis (diagnosis), myocarditis, Myocarditis [Disease/Finding], Myocarditis NOS (disorder), Myocardial inflammation (finding), MYOCARDITIS, Myocarditis (disorder), inflammation; myocardium, myocardium; inflammation, Myocarditis, NOS, Myocardial inflammation
French MYOCARDITE, Myocardite, non précisée, Myocardite SAI, Myocardite
Portuguese MIOCARDITE, Miocardite NE, Miocardite
Spanish MIOCARDITIS, Miocarditis NEOM, Miocarditis no especificada, miocarditis, SAI, inflamación miocárdica (hallazgo), miocarditis, SAI (trastorno), Myocarditis NOS, inflamación miocárdica, miocarditis (trastorno), miocarditis, Miocarditis
Dutch myocarditis, niet-gespecificeerd, myocarditis NAO, myocard; ontsteking, ontsteking; myocard, Myocarditis, niet gespecificeerd, myocarditis, Myocarditis
German Myokarditis NNB, Myokarditis, unspezifisch, MYOCARDITIS, Myokarditis, nicht naeher bezeichnet, Myokarditis
Italian Miocardite NAS, Miocardite non specificata, Miocardite
Japanese 心筋炎ＮＯＳ, 心筋炎�詳細�明, 心筋炎, ｼ�ｷ�ｴ�ｼｮｳｻｲﾌﾒｲ, ｼ�ｷ�ｴ�, ｼ�ｷ�ｴ�NOS
Swedish Hjärtmuskelinflammation
Czech myokard - zánět, zánět srde�ního svalu, myokarditida, Myokarditida, Myokarditida NOS, Myokarditida, blíže neur�ená
Finnish Sydänlihastulehdus
Russian MIOKARDIT, МИОК�РДИТ
Korean �세불명� 심근염
Polish Zapalenie mięśnia sercowego
Hungarian Myocarditis, Myocarditis, nem meghatározott, Myocarditis k.m.n.
Norwegian Hjertemuskelbetennelse, Myokarditt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Viral carditis (C0151328)

Concepts Disease or Syndrome (T047)
ICD10 B33.2 , B33.20
SnomedCT 186755002
German Karditis durch Viren
Korean 바�러스 심장염
English Viral carditis, unspecified, Viral carditis, Viral carditis (disorder), carditis; viral (manifestation), virus; carditis (manifestation)
Spanish carditis vírica, carditis viral (trastorno), carditis viral
Dutch carditis; virus, virus; carditis, Virale carditis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Dilated cardiomyopathy secondary to viral myocarditis (C0264797)

Concepts Disease or Syndrome (T047)
ICD10 B33.24
SnomedCT 30496006
English Viral cardiomyopathy, viral cardiomyopathy, Dilated cardiomyopathy secondary to viral myocarditis, Dilated cardiomyopathy secondary to viral myocarditis (disorder)
Spanish Cardiomiopatía vírica, miocardiopatía dilatada secundaria a miocarditis virósica, miocardiopatía dilatada secundaria a miocarditis viral (trastorno), miocardiopatía dilatada secundaria a miocarditis viral, miocardiopatía dilatada secundaria a miocarditis vírica
Portuguese Cardiomiopatia viral
Dutch virale cardiomyopathie
Italian Cardiomiopatia virale
French Cardiomyopathie virale
German Virus-induzierte Kardiomyopathie
Czech Virová kardiomyopatie
Japanese ｳｲﾙｽｾｲｼ�ｷ�ｼｮｳ, ウイルス性心筋症
Hungarian Vírusos cardiomyopathia
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Viral myocarditis (C0276138)

Concepts Disease or Syndrome (T047)
ICD10 B33.22
SnomedCT 89141000
Italian Miocardite virale, Miocardite virale NAS
Dutch myocarditis viraal NAO, myocarditis; viraal, viraal; myocarditis, virale myocarditis
French Myocardite virale SAI, Myocardite virale
German Myokarditis viral NNB, virale Myokarditis
Portuguese Miocardite viral NE, Miocardite viral
Spanish Miocarditis vírica NEOM, miocarditis virósica, miocarditis vírica, miocarditis viral (trastorno), miocarditis viral, Miocarditis vírica
Japanese ウイルス性心筋炎, ウイルス性心筋炎ＮＯＳ, ｳｲﾙｽｾｲｼ�ｷ�ｴ�NOS, ｳｲﾙｽｾｲｼ�ｷ�ｴ�
Czech Virová myokarditida, Virová myokarditida NOS
English Myocarditis viral NOS, viral myocarditis, myocarditis viral, Viral myocarditis, Viral myocarditis (disorder), myocarditis; viral, viral; myocarditis, Viral myocarditis, NOS
Hungarian vírusos myocarditis, Viralis myocarditis k.m.n.
Derived from the NIH UMLS (Unified Medical Language System)

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