Myocarditis - Prof Djoko Soemantri, MD, PhD, FIHA(1).pdf

8/18/2019 Myocarditis - Prof Djoko Soemantri, MD, PhD, FIHA(1).pdf

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DJOKO SOEMANTRI

MYOCARDITIS


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MYOCARDITISIS AN UNCOMMON DISEASE OF THE HEART CHARACTERIZED BY INFLAMMATION AND SUBSEQUENT

MYOCARDIAL DESTRUCTION

:

THE AVERAGE AGE OF PATIENTS WITH MYOCARDITIS IS 42, THE MALE TO FEMALE RATIO IS 1.5 : 1

OFTEN

NONSPECIFIC

ACUTE

UNLESS

CHFDEVELOPS

OVERT

I N T R O D U C T I O N


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CAUSES OF MYOCARDITIS

VIRUSES ARE THE MOST IMPORTANT INFECTIOUS AGENT1

ENTEROVIRUSES

HIV HAS BEEN SHOWN TO DIRECTLY

ATTACK THE MYOCARDIUM

BACTERIA, CHLAMYDIA, RICKETSSIA, FUNGI AND PROTOZOAN

2

ALONG WITH TOXIN & SYSTEMIC ILLNESS

CHAGAS DISEASE THE MOST COMMON CAUSE OF MYOCARDITIS &

CARDIOMYOPATHY IN CENTRAL AND SOUTH AMERICA

HYPERSENSITIVITY3

PENICILLIN, AMPICILLIN, HCT, METHYLDOPA, SULFONAMIDE

DIRECT CYTOTOXIC EFFECT ON MYOCYTE

4

LITHIUM, DOXORUBICIN, COCAINE, NUMEROUS CATHECOLAMINE & ACETOMINOPHEN


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ENVIROMENTAL TOXIN5

SYSTEMIC DISEASE6

LEAD, ARSENIC, CARBONMONOSIDE

SARCOIDOSIS, CONNECTIVE TISSUE DISORDER, SLE, GIANT CELL ARTERITIS

CAUSES OF MYOCARDITIS


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P T I E N T P R E S E N T T I O N

OFTEN NON SPECIFIC

ACUTE

CONGESTIVE

HEART FAILURE

DEVELOPS

FULMINANT

FATIGUE AND MILDDYSPNEA

60% OF PATIENTS WITH

ANTECEDENT VIRAL SYNDROME

FEVER, FATIGUE, MYALGIA &

MALAISE

TYPICAL TIME

INTERVAL

BETWEEN VIRAL

ILLNESS & CARDIAC

INVOLVEMENT IS 2

WEEKS

ORTOPNEA,

SHORTNESS OF

BREATH

35 % OF PATIENTS

WITH CHEST PAIN

PALPITATIONS

MAY SIGNAL THE

DEVELOPMENT OF AV

BLOCK OR MALIGNANT

DYSRYTHMIAS

SYNCOPE

SUDDEN CARDIAC DEATH

PEDIATRIC (ESPECIALLY INFANTS) WILL PRESENTS WITH NON-SPECIFIC SYMPTOMPS. NEONATAL MYOCARDITIS SHOULD BE CONSIDERED

IN ANY INFANT WITH VIRAL-LIKE ILLNESS WHO DEVELOPS COMPROMISE OF CARDIAC FUNCTION.


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P H Y S I C L E X M I N T I O N

MILD CASE NON-TOXIC APPEARANCE & SIMPLY APPEAR TO HAVE VIRAL SYNDROME

SEVERE CASE HYPOTENSION

CARDIOGENIC SHOCK

S3 & GALLOP

MURMUR OF MITRAL &

TRICUSPID

REGURGITATION

FRICTION RUB

PERICARDIAL EFFUSION

TAMPONADE

POOR PROGNOSIS

MAY BE PRESENT DUE TO

VENTRICULAR DILATION

MAY BE PRESENT IF THERE IS AN

ASSOCIATED PERICARDITIS

PE IS COMMON, BUT SIGNS OF

TAMPONADE IS RARE

TACHYPNEA &

TACHYCARDIAOFTEN OUT OF PROPORTION TO FEVER


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SLOW ELEVATION & FALL OVER A

PERIOD OF DAYS CONTRAST TO

THE MORE ABRUPT RISE IN AMI

P T I E N T S S E S M E N T

LABORATORY

CARDIAC ENZIM OTHERS

(↑) IN MINORITY

PATIENT ONLY

SPECIFIC IF THEY

ARE

DEMONSTRATE

CHARACTERISTIC

ECG PATTERN

(↑) ESR (ERYTROCYTESEDIMENTATION RATE) 60%

OF CASES

(↑) LEUKOCYTOSIS 25%OF CASES

(↑) CRP

BLOOD CULTURE ASO

MYCOPLASMA CULTURES

HEPATITIS PANELMONOSPOT

CMV SEROLOGY

NOT TYPICALLY HELPFUL IN

SECURING THE DIAGNOSIS INEMERGENCY DEPARTEMENT


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CHEST X-RAY (CXR)

OFTEN NORMAL

CARDIAC

SILHOUETTE

CARDIOMEGALY

PLEURAL EFFUSION

ENGORGEDPULMONARY VEINS

INTERSTITIAL

PULMONARY EDEMA

IN YOUNGER PEOPLE

PRESENCE OF

INFILTRAT BILATERAL

LEADS TO

MISDIAGNOSIS

PNEUMONIA

PAC, PVC, SVT, AF, ATRIAL FLUTTER, AV

BLOCK

ELECTROCARDIOGRAM (ECG)

MAY REVEAL A WIDE VARIETY

OF ABNORMALITES

THE MOST COMMON ABNORMALITY IS

SINUS TACHYCARDIA

CARDIAC DYSRHYTHMIAS

SYNCOPE or SUDDEN

CARDIAC DEATH (SCD)

TAVB(TOTAL AV BLOCK)


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SIGNIFICANT SAMPLING ERROR

LEADING TO ONLY 30% PATIENT WITH

POSITIVE BIOPSIES IN WHICH DISEASE

SUSPECTED

DIAGNOSTIC PROCEDURE OF CHOICE


ECHOCARDIOGRAM

NUCLEAR MEDICINE

STUDY

ECHOCARDIOGRAM MYOCARDIAL BIOPSY

IMPAIRMENT LV SYSTOLIC &

DIASTOLIC

IMPAIRMENT EF

PERICARDIAL EFFUSION

RARE

LV THROMBUS 15% OF CASES

SENSITIVITY & SPECIFICITY 83%

NEGATIVE PREDICTIVE VALUE OF 95 %

ENDOMYOCARDIAL BIOPSY

ACTIVE MYOCARDITIS

INFLAMMATORY INFILTRATE OF

THE MYOCARDIUM WITH

NECROSIS & DEGENERATION

OF ADJACENT MYOCYTES NOT

TYPICAL OF ISCHEMIA


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P T I E N T M N G E M E N T

MILD

MILD SYMPTOMS & NO SIGNS

OF CARDIAC FAILURE & NO

DYSSRHYTMIASMAY BE TREATED OUTPATIENTS

SEVERE

LV DYSFUNCTION

LUNG EDEMA

LOW SODIUM DIET

DIGOXIN

VASODILATOR

ACE ICLASS OF DRUGS HAS BEEN SHOWN TO

BENEFICIAL IN THE TREATMENT OF AGENTS

DIURETIC

+

IN GENERAL, SYMPATHOMIMETIC & BETA BLOCKER DRUGS SHOULD BE AVOIDED

IABP

ANTICOAGULATION

LIFE SAVING

REDUCE THE RISK OF

THROMBOEMBOLIZATI

ON IN PATIENTS WITH

DILATED VENTRICLES

RESTRICT ACTIVITY++


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FOR SEVERE HF, SYNCOPE, HEART BLOCK & OTHER DYSRHYTHMIAS

GLUCOCORTICOID, OTHER

IMMUNOSUPPRESIVE DRUGS & NSAID

P T I E N T M N G E M E N T

IMMUNOSUPPRESIVE

THERAPY

LITTLE USE IN THE EMERGENCY

DEPARTEMENT

POTENTIAL TO WORSEN THE ACUTE PHASE

OF VIRAL MYOCARDITIS

ANTIVIRAL THERAPY

PLECONARILBOARD SPECTRUM

ANTIVIRAL DRUGHAS BEEN SHOWN PROMISING RESULT

AGAINTS ENTEROVIRUSES

ADMISSION BED RESTVIRAL MYOCARDITIS IS TYPICALLY A MILD

DISEASE & RESPON WELL TO BED REST

ICCU


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Myocarditis - Prof Djoko Soemantri, MD, PhD, FIHA(1).pdf

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