Epidemiology

• The exact incidence is unknown.

◦ Often occurs in young patients (average age:
∼ 40 years)
◦ In ∼ 10% of sudden deaths in young adults,
myocarditis is diagnosed in the post-mortem
examination.

Etiology
Infectious
• Viral:
Coxsackie B1-B5 (picornavirus), parvovirus B19, human
herpesvirus 6 (HHV-6), adenovirus, HCV, HIV
• Bacterial:
β-hemolytic Streptococcus group A (acute rheumatic fever)
Corynebacterium diphtheriae; diphtheria
Borrelia burgdorferi (borreliosis)
Mycoplasma
• Fungal (candidiasis, aspergillosis)
• Protozoan (Chagas disease, caused by Trypanosoma cruzi, is a common pathogen in South America)
• Parasitic (trichinella, echinococcus)

Noninfectious
• Connective tissue diseases (e.g., SLE)
• Vasculitis syndromes (e.g., Kawasaki disease)
• Toxic myocarditis:
Medication (e.g., sulfonamides), chemotherapy (e.g., anthracycline)
Alcohol, cocaine, Radiation

Clinical features
• Often asymptomatic
• Preceding (1–2 weeks) flue like symptoms
• Fatigue, weakness, dyspnea
• Cardiac arrhythmias: often sinus tachycardia; palpitations or syncope
• Chest pain: indicates pericardial involvement (perimyocarditis)
• Acute decompensated congestive heart failure with dilated cardiomyopathy
• Cardiogenic shock in fulminant cases
• Auscultation findings
Systolic murmurs
Heart failure → S3 (and S4) gallops
Pericarditis → pericardial friction rub

The clinical manifestation of myocarditis is very heterogenous and nonspecific, ranging from
asymptomatic courses to fulminant cardiac decompensation! Be carful!!
Diagnostics
ECG/24-hour Holter monitoring
• Sinus tachycardia
• Arrhythmias
• Repolarization abnormalities:
ST depression
Possible ST elevations with a concave
ascending S wave
• Heart block
• Pericardial effusion: low voltage

Laboratory findings
• ↑ Cardiac enzymes
• ↑ ESR
• Leukocytosis
• ↑ BNP

Imaging
• Chest x-ray and CT:
cardiac enlargement, pulmonary congestion, pleural effusions
• Echocardiography:
Findings often unremarkable
Ventricles: dilation, diffuse hypokinesia, reduced ejection fraction, impaired
contractility, regional wall motion abnormalities
Pericardial effusion: localized or circumferential fl uid surrounding the ventricles
Exclusion of other possible etiologies of heart failure (e.g., heart defects)

Differential diagnoses
• Pericarditis
• Myocardial infarction
+ See differential diagnoses of acute chest/epigastric pain

Treatment
• Supportive therapy:
Inpatient surveillance (cardiac monitoring, oxygen administration, management
of fl uid status)
Rest; avoid physical activity
Analgesic drugs if required
• Causative treatment:
Antibiotic therapy for bacterial myocarditis
Antimycotic therapy (fl uconazole, amphotericin B) for fungal infections
• Treatment of complications:
Congestive heart failure: (e.g., management of fl uid accumulation with diuretics,
beta blockers , ACE inhibitors)
Treatment of cardiac arrhythmias (e.g., amiodarone)
Heart transplantation