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Understanding Myocarditis: Causes, Symptoms, Diagnosis Guidelines

Learn about the various etiological agents causing myocarditis, including viral, bacterial, fungal, parasitic, toxins, autoimmune factors, and expanded criteria for diagnosis. Explore diagnostic modalities' efficacy with sensitivity and specificity ranges.

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Understanding Myocarditis: Causes, Symptoms, Diagnosis Guidelines

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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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