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Myocarditis Clinical Presentation

  • Author: Wai Hong Wilson Tang, MD; Chief Editor: Henry H Ooi, MD, MRCPI  more...
 
Updated: Sep 05, 2014
 

History

Patients with myocarditis have a clinical history of acute decompensation of heart failure, but they have no other underlying cardiac dysfunction or have low cardiac risk. The diagnosis is usually presumptive, based on patient demographics and the clinical course (eg, spontaneous recovery following supportive care).

Patients may present with mild symptoms of chest pain (in concurrent pericarditis), fever, sweats, chills, and dyspnea.

In viral myocarditis, patients may present with a history of recent (within 1-2 wk) flulike syndrome of fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper respiratory tract infection.

Population studies suggest that adults may present with few symptoms, rather than the acute toxic state of cardiogenic shock or frank heart failure (fulminant myocarditis) that is often associated with myocarditis.

Symptoms of palpitations or syncope, or even sudden cardiac death, may develop, due to underlying ventricular arrhythmias or atrioventricular block (especially in giant cell myocarditis).

Adults may present with heart failure years after an initial index event of myocarditis (as many as 12.8% of patients with idiopathic dilated cardiomyopathy had presumed prior myocarditis in one case series).

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Physical Examination

Patients with myocarditis usually present with signs and symptoms of acute decompensation of heart failure (eg, tachycardia, gallop, mitral regurgitation, edema) and, in those with concomitant pericarditis, with pericardial friction rub. Specific findings in special cases are as follows:

  • Sarcoid myocarditis - Lymphadenopathy, also with arrhythmias, sarcoid involvement in other organs (up to 70%)
  • Acute rheumatic fever - Usually affects heart in 50-90%; associated signs, such as erythema marginatum, polyarthralgia, chorea, subcutaneous nodules (Jones criteria)
  • Hypersensitive/eosinophilic myocarditis - Pruritic maculopapular rash and history of using offending drug
  • Giant cell myocarditis - Sustained ventricular tachycardia in rapidly progressive heart failure [1]
  • Peripartum cardiomyopathy - Heart failure developing in the last month of pregnancy or within 5 months following delivery
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Contributor Information and Disclosures
Author

Wai Hong Wilson Tang, MD Professor of Medicine, Section of Heart Failure and Cardiac Transplantation Medicine, Cleveland Clinic Foundation

Wai Hong Wilson Tang, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society for Clinical Investigation, International Society for Heart and Lung Transplantation, Heart Failure Society of America

Disclosure: Nothing to disclose.

Chief Editor

Henry H Ooi, MD, MRCPI Director, Advanced Heart Failure and Cardiac Transplant Program, Nashville Veterans Affairs Medical Center; Assistant Professor of Medicine, Vanderbilt University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Ethan A Booker, MD Attending Physician, Department of Emergency Medicine, Washington Hospital Center

Ethan A Booker, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

George A Stouffer III, MD Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center

George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James B Young, MD Chairman, Professor of Medicine, Department of Medicine, Cleveland Clinic Foundation

Disclosure: National Institute of Health Grant/research funds Independent Contractor

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H and E, low power, showing numerous lymphocytes with associated myocyte damage (photo courtesy of Dr. Donald Weilbaecher)
H and E, high power, showing toxoplasmosis (numerous purple granular-like structures within a myocyte)
H and E, high power, showing lymphocytes, histiocytes and a multinucleated giant cell representing sarcoidosis (a diagnosis of exclusion)
 
 
 
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