INFLAMATION

By : Sari Fatimah

 MYOCARDITIS
PERICARDITIS
ENDOCARDITIS

MYOCARDITIS
myocarditis is inflammation of the
myocardium, the muscular part of the
heart. It is generally due to infection (viral
or bacterial). It may present with chest
pain, rapid signs of heart failure, or sudden
death.

Signs and symptoms of myocarditis

Chest pain (often described as "stabbing" in
character)
Congestive heart failure (leading to edema,
breathlessness and hepatic congestion)
Palpitations (due to arrhythmias)
Sudden death (in young adults, myocarditis
causes up to 20% of all cases of sudden
death)[2]
Fever (especially when infectious, e.g. in
rheumatic fever

 Elevated CRP and/or ESR and increased IgM (serology) against

viruses known to affect the myocardium. Markers of myocardial
damage (troponin or creatine kinase cardiac isoenzymes) are
elevated.[1]
The ECG findings most commonly seen in myocarditis are diffuse T
wave inversions; saddle-shaped ST-segment elevations may be
present (these are also seen in pericarditis).[1]
The gold standard is still biopsy of the myocardium, generally done in
the setting of angiography. A small tissue sample of the endocardium
and myocardium is taken, and investigated by a pathologist by light
microscopy andif necessaryimmunochemistry and special staining
methods. Histopathological features are: myocardial interstitium with
abundant edema and inflammatory infiltrate, rich in lymphocytes and
macrophages. Focal destruction of myocytes explains the myocardial
pump failure.[1]
Recently, cardiac magnetic resonance imaging (cMRI or CMR) has
been shown to be very useful in diagnosing myocarditis by visualizing
markers for inflammation of the myocardium.[3]

Etiology

Infectious:

Immunological:

Allergic (e.g. acetazolamide, amitriptyline)

Rejection after a heart transplant
Autoantigens (e.g. systemic vasculitis such as Churg-Strauss syndrome, Wegener's
granulomatosis)

Toxic:

Viral (e.g. enterovirus, Coxsackie virus, rubella virus, polio virus, cytomegalovirus, possibly
hepatitis C)
Bacterial (e.g. brucella, Corynebacterium diphtheriae, gonococcus, Haemophilus influenzae,
Actinomyces, Tropheryma whipplei, and Vibrio cholerae).
Spirochetal (Borrelia burgdorferi and leptospirosis)
Protozoal (Toxoplasma gondii and Trypanosoma cruzi)
Fungal (e.g. aspergillus)
Parasitic: ascaris, Echinococcus granulosus, Paragonimus westermani, schistosoma, Taenia
solium, Trichinella spiralis, visceral larva migrans, and Wuchereria bancrofti
Rickettsial

Drugs (e.g. anthracyclines and some other forms of chemotherapy, ethanol, and antipsychotics,
e.g. clozapine)
Toxins (e.g. arsenic, carbon monoxide, snake venom)
Heavy metals (e.g. copper, iron)

Physical agents (electric shock, hyperpyrexia, and radiation)

PERICARDITIS
an inflammation (-itis) of the pericardium
(the fibrous sac surrounding the heart).
Pericarditis is further classified according
to the composition of the inflammatory
exudate: serous, purulent, fibrinous, and
hemorrhagic types are distinguished.[1]
Acute pericarditis is more common than
chronic pericarditis, and can occur as a
complication of infections, immunologic
conditions, or heart attack.

Clinical presentation
Chest pain, radiating to the back and relieved by
sitting up forward and worsened by lying down, is
the classical presentation. Other symptoms of
pericarditis may include dry cough, fever, fatigue
and anxiety. Pericarditis can be misdiagnosed as
myocardial infarction (heart attack), and vice versa.
The classic sign of pericarditis is a friction rub.
Other signs include diffuse ST-elevation and PRdepression on EKG (all leads); cardiac tamponade
(pulsus paradoxus with hypotension), and
congestive heart failure (elevated jugular venous
pressure with peripheral edema).

Causes

Idiopathic No identifiable etiology found after routine testing.

Viral infection, especially by Coxsackie virus (most common cause)
Bacterial infection, especially by the Tuberculosis bacillus
Fungal
Immunologic conditions including Lupus erythematosus (more common
among women)
Myocardial Infarction (Dressler's syndrome)
Trauma to the heart, e.g. puncture, resulting in infection or
inflammation
Uremia
Malignancy (as a paraneoplastic phenomenon)
Side effect of some medications, e.g. isoniazid, cyclosporine,
hydralazine
Radiation induced
Aortic dissection
Tetracyclines

Complications
Complications may include:
Pericardial effusion
Constrictive pericarditis
Cardiac tamponade [1]

Pericarditis due to Tuberculosis

is difficult to diagnose, because definitive diagnosis requires
culturing Mycobacterium tuberculosis from aspirated pericardial fluid
or pericardial biopsy, which requires high technical skill and is often
not diagnostic (the yield from culture is low even with optimum
specimens).
The Tygerberg scoring system helps the clinician to decide whether
pericarditis is due to tuberculosis or whether it is due to another
cause: night sweats (1 point), weight loss (1 point), fever (2 point),
serum globulin > 40g/l (3 points), blood total leucocyte count <10 x
109/l (3 points); a total score of 6 or more is highly suggestive of
tuberculous pericarditis.[2] Pericardial fluid with an interferon- level
greater than 50pg/ml is highly specific for tuberculous pericarditis

Treatment
The treatment in viral or idiopathic
pericarditis is with non-steroidal antiinflammatory drugs. Severe cases may
require:
pericardiocentesis
antibiotics
steroids
colchicine
surgery

ENDOCARDITIS
is an inflammation of the inner layer of the
heart, the endocardium. The most
common structures involved are the heart
valves.
Endocarditis can be classified by etiology
as either infective or non-infective,
depending on whether a microorganism is
the source of the problem

Classification

infective endocarditis has been clinically divided into acute and subacute
(because the patients tend to live longer in subacute as opposed to acute)
endocarditis. This classifies both the rate of progression and severity of
disease. Thus subacute bacterial endocarditis (SBE) is often due to
streptococci of low virulence and mild to moderate illness which progresses
slowly over weeks and months, while acute bacterial endocarditis (ABE) is a
fulminant illness over days to weeks, and is more likely due to
Staphylococcus aureus which has much greater virulence, or diseaseproducing capacity.
This terminology is now discouraged. The terms short incubation (meaning
less than about six weeks), and long incubation (greater than about six
weeks) are preferred.[citation needed]
Infective endocarditis may also be classified as culture-positive or culturenegative. Culture-negative endocarditis is due to micro-organisms that
require a longer period of time to be identified in the laboratory. Such
organisms are said to be 'fastidious' because they have demanding growth
requirements. Some pathogens responsible for culture-negative
endocarditis include Aspergillus species, Brucella species, Coxiella burnetii,
Chlamydia species, and HACEK bacteria.

Etiology
As previously mentioned, altered blood flow around the
valves is a risk factor in obtaining endocarditis. The
valves may be damaged congenitally, from surgery, by
auto-immune mechanisms, or simply as a consequence
of old age. The damaged part of a heart valve becomes
covered with a blood clot, a condition known as nonbacterial thrombotic endocarditis (NBTE).
In a healthy individual, a bacteremia (where bacteria get
into the blood stream through a minor cut or wound)
would normally be cleared quickly with no adverse
consequences. If a heart valve is damaged and covered
with a piece of a blood clot, the valve provides a place
for the bacteria to attach themselves and an infection
can be established.

 The bacteremia is often caused by dental procedures, such

as a cleaning or extraction of a tooth. It is important that a
dentist or a dental hygienist is told of any heart problems
before commencing. Antibiotics are administered to patients
with certain heart conditions as a precaution.
Another group of causes result from a high number of
bacteria getting into the bloodstream. Colorectal cancer,
serious urinary tract infections, and IV drug use can all
introduce large numbers of bacteria. With a large number of
bacteria, even a normal heart valve may be infected. A more
virulent organism (such as Staphylococcus aureus, but see
below for others) is usually responsible for infecting a normal
valve.
Intravenous drug users tend to get their right heart valves
infected because the veins that are injected enter the right
side of the heart. The injured valve is most commonly
affected when there is a pre-existing disease. (In rheumatic
heart disease this is the aortic and the mitral valves, on the
left side of the heart.)

Clinical and pathological features

Fever, i.e. fever of unknown origin (often spiking caused by
septic emboli)
Continuous presence of micro-organisms in the bloodstream
determined by serial collection of blood cultures
Vegetations on valves on echocardiography, which sometimes
can cause a new or changing heart murmur, particularly
murmurs suggestive of valvular regurgitation
Vascular phenomena: (causing thromboembolic problems such
as stroke in the parietal lobe of the brain or gangrene of
fingers), Janeway lesions (painless hemorrhagic cutaneous
lesions on the palms and soles), intracranial hemorrhage, ,
Immunologic phenomena: Glomerulonephritis, Osler's nodes
(painful subcutaneous lesions in the distal fingers), Roth's spots
on the retina, positive serum rheumatoid factor

Diagnosis
The most important investigation is Blood
culture. In general, a patient should fulfill the
Duke Criteria[1] in order to establish the
diagnosis of endocarditis
Echocardiography
The transthoracic echocardiogram has a
sensitivity and specificity of approximately 65%
and 95% if the echocardiographer believes there
is 'probabable' or 'almost certain' evidence of
endocarditis

BACTERIAL ENDOCARDITIS
also called infective endocarditis) is an infection of
the heart valves or the hearts inner lining
(endocardium).
Bacterial endocarditis occurs when germs
(especially bacteria but occasionally fungi and
other microbes) enter the blood stream and attack
the lining of the heart or the heart valves. Bacterial
endocarditis causes growths or holes on the valves
or scarring of the valve tissue, most often resulting
in a leaky heart valve. Without treatment, bacterial
endocarditis can be a fatal disease.
Normally, bacteria can be found in the mouth, on
the skin, in the intestines

Who is at risk for developing bacterial

endocarditis

Patients most at risk of developing bacterial endocarditis

include those who have:
An artificial (prosthetic) heart valve, including bioprosthetic
and homograft valves
Previous bacterial endocarditis
Certain congenital heart diseases
Acquired valve disease (for example, rheumatic heart
disease)
Heart valve disease that develops after heart transplantation
Hypertrophic cardiomyopathy (HCM)
Mitral valve prolapse with valve regurgitation (leaking) and/or
thickened valve leaflets

How is bacterial endocarditis diagnosed?

The diagnosis of bacterial endocarditis is based on the presence of symptoms :

Symptoms of infection (see the next page), particularly a fever over 100F
(38.4C)
Blood cultures show bacteria or microorganisms commonly found with
endocarditis. Blood cultures are blood tests taken over time that allow the
laboratory to isolate the specific bacteria that is causing your infection. They
must be taken before antibiotics are started to determine if you have
endocarditis.
Echocardiogram (ultrasound of the heart) may show growths, abscesses
(holes), new regurgitation (leaking) or stenosis (narrowing), or an artificial heart
valve that has begun to pull away from the heart tissue. Sometimes doctors
insert an ultrasound probe into the esophagus or food pipe (transesophageal
echo) to obtain a very detailed look at the heart.
Other signs and symptoms of bacterial endocarditis include:

Emboli (small blood clots), hemorrhages (internal bleeding), or stroke

Shortness of breath
Night sweats
Poor appetite or weight loss
Muscle and joint ache

Signs of infection:

Fever over 100F(38.4C)

Sweats or chills, particularly night sweats
Skin rash
Pain, tenderness, redness or swelling
Wound or cut that won't heal
Red, warm or draining sore
Sore throat, scratchy throat or pain when swallowing
Sinus drainage, nasal congestion, headaches or tenderness along
upper cheekbones
Persistent dry or moist cough that lasts more than two days
White patches in your mouth or on your tongue
Nausea, vomiting or diarrhea

How is bacterial endocarditis treated?

After the specific bacteria causing the endocarditis are
identified from blood culture tests, a course of intravenous
(IV) antibiotic therapy is started. IV antibiotics may be
given for as long as 6 weeks to control the infection.
Symptoms are monitored throughout therapy and blood
tests are performed to determine the effectiveness of
treatment.
If heart valve damage has occurred, surgery may be
required to fix the heart valve and improve heart function.
Bacterial endocarditis treatment starts with
prevention. Once endocarditis occurs, quick treatment is
necessary to prevent damage to the heart valves and
more serious complications, such as death

Rheumatic Heart Disease

is a condition in which the heart valves are
damaged by rheumatic fever.
Rheumatic fever begins with a strep throat from
streptococcal infection.
Rheumatic fever is an inflammatory disease. It
can affect many of the body's connective tissues
especially those of the heart, joints, brain or skin.
Anyone can get acute rheumatic fever, but it
usually occurs in children five to 15 years old.
The rheumatic heart disease that results can last
for life.

What are the symptoms of rheumatic heart

disease?
Symptoms vary greatly. Often the damage to
heart valves isn't immediately noticeable. A
damaged heart valve either doesn't fully close or
doesn't fully open.
Eventually, damaged heart valves can cause
serious, even disabling, problems. These
problems depend on how bad the damage is and
which heart valve is affected. The most advanced
condition is congestive heart failure. This is a
heart disease in which the heart enlarges and
can't pump out all its blood.

 Some of the most common symptoms of

rheumatic heart disease are:
breathlessness, fatigue, palpitations,
chest pain, and fainting attacks.

Diagnosis
Medical history including evidence of past
rheumatic fever or strep infection
Blood tests to check for the presence of
inflammation and past exposure to Group A
streptococcus
Chest x-ray to check for enlargement of the heart
or fluid on the lungs
Electrocardiogram to check if the chambers of
the heart have enlarged or if there is an abnormal
heart rhythm (arrhythmia)
Echocardiogram to check the heart valves for
any damage or infection, and to check for evidence
of muscle damage or cardiac (heart) failure