History

Fact Explanation
Symptoms of heart failure [2] Patients can present with acute onset dyspnea, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and dependent edema are due to acute heart failure. [9] Rapidly progressing heart failure is commonly seen in giant cell myocarditis.
Chest pain [3] Some patients with myocarditis may complain of chest pain.
Fever Fever occurs due to inflammation of the myocardium. Sweating and chills can be associated with fever. Sometimes fever may be a preceding non-specific symptom. [4]
Dyspnea Most of the patients have dyspnea. This might be attributed to the development of heart failure and also to preceding viral upper respiratory tract infection. Dyspnea can be either at rest or with exertion. [3,4]
History of recent viral illness Post viral acute myocarditis can occur within 1to 2 weeks of viral illness. Flu and other upper respiratory tract infections and gastrointestinal infections can result in viral myocarditis. Before the onset of symptoms of heart failure patient may complain of fatigue, dyspnea, palpitations, malaise, and non-specific chest discomfort. [1,2]
Palpitations Due to ventricular arrhythmias or atrio-ventricular block. This is a non-specific symptom. [4]
Syncope Can occur secondary to ventricular arrhythmias or atrio-ventricular block. [4]
Sudden cardiac death A relatively rare presentation and is due to ventricular arrhythmias or atrio-ventricular block. [4]
History of drug ingestion Certain drugs like phenothiazines and other anti-epileptics can cause myocarditis. [5,6]
Skin rash Pruritic, maculopapular or generalized erythematous skin rash can occur in drug induced myocarditis. [6]
History of pregnancy Postpartum myocarditis can occur during the last trimester of pregnancy or within 5 months following delivery. [7,8]
References
  1. HARADA Y, TOMINO S, OGAWA K, WADA T, MORI S, KOBAYASHI S, KIYOSUE T, KUBO H. [Frequency of three-rooted mandibular first molars. Survey by x-ray photographs]. Shika Kiso Igakkai Zasshi [online] 1989 Feb, 31(1):13-8 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2519249
  2. YAJIMA T., KNOWLTON K. U.. Viral Myocarditis: From the Perspective of the Virus. Circulation [online] December, 119(19):2615-2624 [viewed 23 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.108.766022
  3. SCHULTZ JC, HILLIARD AA, COOPER LT JR, RIHAL CS. Diagnosis and Treatment of Viral Myocarditis Mayo Clin Proc [online] 2009 Nov, 84(11):1001-1009 [viewed 23 June 2014] Available from: doi:10.1016/S0025-6196(11)60670-8
  4. MAGNANI J. W.. Myocarditis: Current Trends in Diagnosis and Treatment. Circulation [online] 2006 February, 113(6):876-890 [viewed 23 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.105.584532
  5. ANSARI A, MARON BJ, BERNTSON DG. Drug-Induced Toxic Myocarditis Tex Heart Inst J [online] 2003, 30(1):76-79 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC152844
  6. KOCAOGLU CELEBI, CILASUN CEYDA, SOLAK ECE SELMA, KURTIPEK GULCAN S., ARSLAN SUKRU. Successful Treatment of Antiepileptic Drug-Induced DRESS Syndrome with Pulse Methylprednisolone. Case Reports in Pediatrics [online] 2013 December, 2013:1-4 [viewed 24 June 2014] Available from: doi:10.1155/2013/928910
  7. YAGORO A, TADA H, HIDAKA Y, OHNISHI Y, NAGATA S, SATO H, AMINO N. Postpartum onset of acute heart failure possibly due to postpartum autoimmune myocarditis. A report of three cases. J Intern Med [online] 1999 Feb, 245(2):199-203 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10081523
  8. RAMARAJ R., SORRELL V. L.. Peripartum cardiomyopathy: Causes, diagnosis, and treatment. Cleveland Clinic Journal of Medicine [online] December, 76(5):289-296 [viewed 24 June 2014] Available from: doi:10.3949/ccjm.76a.08004
  9. KING M, KINGERY J, CASEY B. Diagnosis and evaluation of heart failure. Am Fam Physician [online] 2012 Jun 15, 85(12):1161-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22962896

Examination

Fact Explanation
Pulse Tachycardia can occur due to heart failure. [1] Arrhythmias can also be detected. Sustained ventricular tachycardia is seen in giant cell myocarditis.
Gallop rhythm [1] Third heart sound can occur due to heart failure. First heart sound can be diminished. [1,2]
Pulmonary crackles Diffuse pulmonary crackles are heard due to pulmonary edema secondary to heart failure. [2]
Mitral regurgitation A murmur of mitral regurgitation can occur. [1]
Tricuspid regurgitation Murmur of tricuspid regurgitation can present. [1]
Edema Due to heart failure. Peripheral and dependent edema is seen. [2]
Pericardial friction rub [1] A pericardial rub can rarely occur in myocarditis if the patient has pericarditis as well.
Lymphadenopathy Lymphadenopathy is seen in sarcoid myocarditis. [3]
Skin involvement Maculopapular rash is seen in drug induced myocarditis. [4]
References
  1. HARADA Y, TOMINO S, OGAWA K, WADA T, MORI S, KOBAYASHI S, KIYOSUE T, KUBO H. [Frequency of three-rooted mandibular first molars. Survey by x-ray photographs]. Shika Kiso Igakkai Zasshi [online] 1989 Feb, 31(1):13-8 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2519249
  2. KING M, KINGERY J, CASEY B. Diagnosis and evaluation of heart failure. Am Fam Physician [online] 2012 Jun 15, 85(12):1161-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22962896
  3. BOGABATHINA HARI, OLSON PETER, RATHI VIKAS K., BIEDERMAN ROBERT W. W.. Cardiac Sarcoidosis or Giant Cell Myocarditis? On Treatment Improvement of Fulminant Myocarditis as Demonstrated by Cardiovascular Magnetic Resonance Imaging. Case Reports in Cardiology [online] 2012 December, 2012:1-5 [viewed 24 June 2014] Available from: doi:10.1155/2012/647041
  4. KOCAOGLU CELEBI, CILASUN CEYDA, SOLAK ECE SELMA, KURTIPEK GULCAN S., ARSLAN SUKRU. Successful Treatment of Antiepileptic Drug-Induced DRESS Syndrome with Pulse Methylprednisolone. Case Reports in Pediatrics [online] 2013 December, 2013:1-4 [viewed 24 June 2014] Available from: doi:10.1155/2013/928910

Differential Diagnoses

Fact Explanation
Acute coronary syndrome Chest pain is common in both conditions. Patients complain of constricting type left sided chest pain, which radiates to the left arm and jaw. [1]
Cardiogenic pulmonary edema Acute left heart failure or acute on chronic heart failure can cause cardiogenic pulmonary edema. Myocardial infarction is one of the commonest causes of acute left heart failure. [2,3]
Pulmonary fibrosis Pulmonary fibrosis is an age related chronic fibrosis of the pulmonary parenchyma. Progressive destruction of lung tissue can cause dyspnea. [4]
Sudden cardiac death Short history of (usually less than 1 hour) chest pain, palpitations and dyspnea is common. [5]
Cardiomyopathy Cardiomyopathies can be either primary (genetic, nongenetic, acquired) or secondary to a systemic disease. [6]
Chagas Disease Cardiac complications of chronic Chagas disease include cardiomyopathy, heart failure and , altered heart rate or rhythm, and cardiac arrest. [7]
References
  1. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 20 June 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  2. JOSEPH SM, CEDARS AM, EWALD GA, GELTMAN EM, MANN DL. Acute Decompensated Heart Failure: Contemporary Medical Management Tex Heart Inst J [online] 2009, 36(6):510-520 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801958
  3. ALCALDE O., DOMINGO E., FIGUERAS J.. Recurrent Severe Acute Pulmonary Edema Caused by Transient Left Ventricular Insufficiency With Mitral Regurgitation Related to Severe Coronary Artery Spasm. Circulation: Heart Failure [online] December, 3(2):332-335 [viewed 24 June 2014] Available from: doi:10.1161/CIRCHEARTFAILURE.109.921957
  4. KING TALMADGE E, PARDO ANNIE, SELMAN MOISéS. Idiopathic pulmonary fibrosis. The Lancet [online] 2011 December, 378(9807):1949-1961 [viewed 25 June 2014] Available from: doi:10.1016/S0140-6736(11)60052-4
  5. ZIPES D. P., WELLENS H. J. J.. Sudden Cardiac Death. Circulation [online] 1998 November, 98(21):2334-2351 [viewed 25 June 2014] Available from: doi:10.1161/01.CIR.98.21.2334
  6. MARON B. J.. Contemporary Definitions and Classification of the Cardiomyopathies: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation [online] 2006 April, 113(14):1807-1816 [viewed 25 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.106.174287
  7. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online] 17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X

Investigations - for Diagnosis

Fact Explanation
Full blood count Leukocytosis is seen due to inflammation. [5,7]
Erythrocyte sedimentation rate Elevated due to inflammation, but this has very low sensitivity and specificity. [6]
C-reactive protein Elevated due to inflammation. [7]
Electrocardiogram (ECG) [2] ECG changes are often nonspecific. Sometimes sinus tachycardia and ventricular arrhythmia can be detected. Nonspecific ST- or T-wave changes, PQ-segment depression can also be seen. Sometimes ST segment elevation can mimic ECG changes of a myocardial infarction. [2]
Chest X-ray [2] Features of heart failure (pulmonary edema, Kerley B lines, upper lobe diversion, pleural effusions) can be seen.
Cardiac enzymes Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Creatine kinase or cardiac troponins are commonly assessed. [2] Cardiac troponin (troponin I or T). identify patients with resolution of viral myocarditis, better than creatinine kinase MB. [7]
Serum viral antibody titers Viral antibody titers can be assessed if post viral myocarditis is suspected. Commonly group B coxsackie virus, parvovirus B19, human immunodeficiency virus, cytomegalovirus, Ebstein-Barr virus, hepatitis viruses, and influenza viruses can cause myocarditis. [1,2]
Endomyocardial biopsy [2] Endomyocardial biopsy samples are used to assess the presence of viral genomes (by viral polymerase chain reaction) and also used for histological diagnosis of myocarditis. Lymphocyte infiltration and myocyte necrosis are histological findings. Dallas criteria are used for the histological diagnosis of myocarditis. [1,3]
Echocardiography Echocardiogram can roughly locate the site of inflammation. Abnormal wall motions, enlarged left ventricle, diastolic dysfunction and the presence of pericardial effusion are suggestive of myocarditis. [2]
Gadolinium scan This is a very sensitive test to assess the extent of inflammation and cellular edema. [2]
Cardiac MRI [2] Cardiac MRI has sensitivity of 100% and specificity of 90% in diagnosing myocarditis by detecting sites of inflammation. [4]
Autoantibodies Autoimmune etiology is also responsible for the development of myocarditis. Screening of common cardiac autoantibodies (antibodies against cardiac myosin heavy chain) is helpful in diagnosing. [1,2]
References
  1. HEYMANS S.. Myocarditis and heart failure: need for better diagnostic, predictive, and therapeutic tools. European Heart Journal [online] 2007 June, 28(11):1279-1280 [viewed 22 June 2014] Available from: doi:10.1093/eurheartj/ehm111
  2. HARADA Y, TOMINO S, OGAWA K, WADA T, MORI S, KOBAYASHI S, KIYOSUE T, KUBO H. [Frequency of three-rooted mandibular first molars. Survey by x-ray photographs]. Shika Kiso Igakkai Zasshi [online] 1989 Feb, 31(1):13-8 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2519249
  3. YAJIMA T., KNOWLTON K. U.. Viral Myocarditis: From the Perspective of the Virus. Circulation [online] December, 119(19):2615-2624 [viewed 23 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.108.766022
  4. DEUX JF, MAATOUK M, LIM P, VIGNAUD A, MAYER J, GUERET P, RAHMOUNI A. Acute myocarditis: diagnostic value of contrast-enhanced cine steady-state free precession MRI sequences. AJR Am J Roentgenol [online] 2011 Nov, 197(5):1081-7 [viewed 23 June 2014] Available from: doi:10.2214/AJR.10.603
  5. AKUZAWA NOBUHIRO, HARADA NAOYUKI, HATORI TAKASHI, IMAI KUNIHIKO, KITAHARA YONOSUKE, SAKURAI SHINJI, KURABAYASHI MASAHIKO. Myocarditis, hepatitis, and pancreatitis in a patient with coxsackievirus A4 infection: a case report. Array [online] 2014 December [viewed 25 June 2014] Available from: doi:10.1186/1743-422X-11-3
  6. MAGNANI J. W.. Myocarditis: Current Trends in Diagnosis and Treatment. Circulation [online] 2006 February, 113(6):876-890 [viewed 25 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.105.584532
  7. SCHULTHEISS H.-P., KUHL U., COOPER L. T.. The management of myocarditis. European Heart Journal [online] December, 32(21):2616-2625 [viewed 25 June 2014] Available from: doi:10.1093/eurheartj/ehr165

Management - General Measures

Fact Explanation
Basic life support Assessment of the airway, breathing and circulation should be the first step in patient management. Oxygen should be delivered if necessary. Patient should be connected to a cardiac monitor. Administration of intravenous fluid is considered if necessary. Some patients with severe cardiac failure and cardiogenic shock may require mechanical cardiac support. [4]
Vaccination Vaccination against measles, rubella, mumps, poliomyelitis, and influenza can prevent myocarditis caused by those infections. [2]
Dietary advice Patients are advised to consume a low-sodium diet and to restrict fluid as it can cause a state of fluid overload. [5]
Physical rest Bed rest is recommended for all patients. Patients should seek medical advice before the commencement of strenuous activities. [1]
Stop the offending drug In drug induced myocarditis, the offending drug should be stopped. [3]
Treatment of infection In viral myocarditis, the underlying infection is better treated. [2]
Antiarrhythmics Antiarrhythmics are indicated in arrhythmias. But caution should be applied as most of the antiarrhythmatics have negative inotropic actions. [1]
References
  1. HARADA Y, TOMINO S, OGAWA K, WADA T, MORI S, KOBAYASHI S, KIYOSUE T, KUBO H. [Frequency of three-rooted mandibular first molars. Survey by x-ray photographs]. Shika Kiso Igakkai Zasshi [online] 1989 Feb, 31(1):13-8 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2519249
  2. YAJIMA T., KNOWLTON K. U.. Viral Myocarditis: From the Perspective of the Virus. Circulation [online] December, 119(19):2615-2624 [viewed 23 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.108.766022
  3. ANSARI A, MARON BJ, BERNTSON DG. Drug-Induced Toxic Myocarditis Tex Heart Inst J [online] 2003, 30(1):76-79 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC152844
  4. MAGNANI J. W.. Myocarditis: Current Trends in Diagnosis and Treatment. Circulation [online] 2006 February, 113(6):876-890 [viewed 25 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.105.584532
  5. SCHULTZ JC, HILLIARD AA, COOPER LT JR, RIHAL CS. Diagnosis and Treatment of Viral Myocarditis Mayo Clin Proc [online] 2009 Nov, 84(11):1001-1009 [viewed 25 June 2014] Available from: doi:10.1016/S0025-6196(11)60670-8

Management - Specific Treatments

Fact Explanation
Conservative management Most of the patients with post viral myocarditis may recover spontaneously. These patients only need supportive management of heart failure. [1]
Management of heart failure Diuretics, beta blockers and angiotensin-converting enzyme (ACE) inhibitors are preferred. Inotropic drugs (eg, dobutamine, milrinone) should be used whenever necessary. [2]
Immune suppression Immune suppression is effective in patients with autoimmune myocarditis. Corticosteroids can be used for immune modulation but it does not reduce mortality. [1,3]
Pace makers Patients with Mobitz type II or complete heart block usually require a temporary pacemaker. Permanent pacer or automatic implantable cardioverter-defibrillator (AICD) placement may be needed in some patients.
Management of tachycrrhythmia Atrial tachycardia, and ventricular tachycardia are recognized complications of acute myocarditis. Antiarrhythmics should be prescribed to control these tachyarrhythmias. [4,5]
Heart transplantation Cardiac transplantation may be needed especially in biopsy proven giant cell myocarditis. [2]
References
  1. HEYMANS S.. Myocarditis and heart failure: need for better diagnostic, predictive, and therapeutic tools. European Heart Journal [online] 2007 June, 28(11):1279-1280 [viewed 22 June 2014] Available from: doi:10.1093/eurheartj/ehm111
  2. HARADA Y, TOMINO S, OGAWA K, WADA T, MORI S, KOBAYASHI S, KIYOSUE T, KUBO H. [Frequency of three-rooted mandibular first molars. Survey by x-ray photographs]. Shika Kiso Igakkai Zasshi [online] 1989 Feb, 31(1):13-8 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2519249
  3. CHEN HS, WANG W, WU SN, LIU JP. Corticosteroids for viral myocarditis. Cochrane Database Syst Rev [online] 2013 Oct 18:CD004471 [viewed 23 June 2014] Available from: doi:10.1002/14651858.CD004471.pub3
  4. PETRONI DH, YANG SG, KATTASH MM, SNYDER CS. Management of Atrial Tachycardia in the Newborn With Enterovirus Myocarditis Ochsner J [online] 2012, 12(2):163-166 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387845
  5. MAZZONE P., TSIACHRIS D., DELLA BELLA P.. Epicardial management of myocarditis-related ventricular tachycardia. European Heart Journal [online] December, 34(3):244-244 [viewed 25 June 2014] Available from: doi:10.1093/eurheartj/ehs316