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Etiological Agents Causing Myocarditis Viral (Most Common)  Adenovirus  

Etiological Agents Causing Myocarditis Viral (Most Common)  Adenovirus    Coxsackie virus/Enterovirus    Cytomegalovirus    Parvovirus B19    Hepatitis C virus    Influenza    Human immunodeficiency virus    Herpes virus    Epstein-Barr virus    Mixed infections    . Bacterial

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Etiological Agents Causing Myocarditis Viral (Most Common)  Adenovirus  

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  1. Etiological Agents Causing Myocarditis • Viral (Most Common) •  Adenovirus   •  Coxsackie virus/Enterovirus    • Cytomegalovirus    • Parvovirus B19    • Hepatitis C virus   •  Influenza    • Human immunodeficiency virus    • Herpes virus   •  Epstein-Barr virus    • Mixed infections    

  2. Bacterial • Mycobacterial species    • Chlamydia pneumoniae •  Streptococcal species    • Mycoplasma pneumoniae • Treponema pallidum • Fungal • Aspergillus    • Candida   •  Coccidioides    • Cryptococcus    • Histoplasma    • ProtozoalTrypanosoma cruzi • Parasitic   Schistosomiasis   Larva migrans   

  3. Toxins Anthracyclines    Cocaine    Hypersensitivity Clozapine    Sulfonamides    Cephalosporins    Penicillins    ricyclic antidepressants    Autoimmune Activation   Smallpox vaccination    Giant cell myocarditis   Churg-Strauss syndrome    Sjögren syndrome  Inflammatory bowel disease    Celiac disease    Sarcoidosis    Systemic lupus erythematosus    Takayasu arteritis    Wegener granulomatosis

  4.  Expanded Criteria for Diagnosis of Myocarditis • Suspicious for myocarditis = 2 positive categoriesCompatible with myocarditis = 3 positive categories • High probability of being myocarditis = all 4 categories positive(Any matching feature in category = positive for category)   Category I: Clinical Symptoms • Clinical heart failure    • Fever   •  Viral prodrome   •  Fatigue •  Dyspnea on exertion    • Chest pain    • Palpitations   •  Presyncope or syncope    

  5. Category II: Evidence of Cardiac Structural/Functional Perturbation in the Absence of Regional Coronary Ischemia • Echocardiography evidence    • Regional wall motion abnormalities   •  Cardiac dilation    • Regional cardiac hypertrophy    • Troponin release   High sensitivity (>0.1 ng/ml)    • Positive indium-111 antimyosin scintigraphy   and   Normal coronary angiography or   Absence of reversible ischemia by coronary distribution on perfusion scan

  6. Category III: Cardiac Magnetic Resonance Imaging   I • ncreased myocardial T2 signal on inversion recovery sequence   •  Delayed contrast enhancement following gadolinium-DTPA infusion    Category IV: Myocardial Biopsy—Pathological or Molecular Analysis • Pathology findings compatible with Dallas criteria    • Presence of viral genome by polymerase chain reaction or in situ hybridization

  7. Comparison of Efficacy of Various Diagnostic Modalities for Myocarditis • Diagnostic Modality Sensitivity Range Specificity Range • ECG changes (e.g., AV block, Q, ST changes) 47% ? • Troponin (lower threshold of >0.1 mg/ml) 34%-53% 89%-94% • CK-MB 6% ? • Antibodies to virus or myosin 25%-32% 40% • Indium-111 antimyosin scintigraphy 85%-91% 34%-53% • Echocardiography (ventricular dysfunction) 69% ? • Cardiac magnetic resonance imaging 86% 95% • Myocardial biopsy (Dallas criteria of pathology) 35%-50% 78%-89% • Myocardial biopsy (viral genome by PCR) 38%-65% 80%-100% • ? = indeterminant or poor; AV = atrioventricular; CK-MB = cytosine kinase isoenzyme; ECG = electrocardiogram; PCR = polymerase chain reaction.

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