Myocardial Abscess Clinical Presentation

  • Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 11, 2012
 

History

Physicians must maintain a high index of suspicion to diagnose patients who have myocardial abscess. Many of the clinical features of this condition reflect the symptoms and signs of the clinical setting that predisposes to development of the abscess.

  • Infective endocarditis is associated with the following:
    • Significant clinical deterioration, including worsening CHF, worsening heart sounds and murmurs, and new-onset valvular regurgitation (100% of cases)[11]
    • Poor response to antibiotics
    • Development of conduction defects or progression of heart block, such as bundle-branch block and atrioventricular block (45%)[2]
    • Sudden onset of complete heart block or Mobitz type II block (highly specific)
    • Type of valve involvement, eg, aortic valve endocarditis (40%-85% incidence)
    • Severe recurrent ventricular arrhythmias
    • Pericarditis (uncommon)
    • Infection of the prosthetic valves (bioprosthetic or metallic)
    • Right-sided endocarditis in patients with congenital heart disease
  • The duration of symptoms is short.
  • Fever is protracted despite adequate antibiotic coverage.
  • The infecting organism is Pneumococcus or Staphylococcus species.
  • Acute MI occurs in the setting of septicemia.
  • Sepsis may be present in patients with a penetrating chest injury.
  • Myocardial abscess is more prevalent in the period following mechanical interventions or surgery and in patients with HIV/AIDS-related myocarditis.
  • Most cases of myocardial abscess occur in the setting of infective endocarditis. Symptoms and signs mainly reflect the presence of infective endocarditis. The clinical features persist or worsen upon development of a complicating myocardial abscess.
  • Myocardial abscess must be considered in patients who have longstanding persistent bacteremia and who do not respond to antibiotic therapy.
  • One must bear in mind certain constellations of symptoms that may raise the suggestion of myocardial abscess. For example, fever is the most common symptom, presenting in 80%-85% of patients. It is absent in some patients who are elderly; those who have CHF, severe debility, or chronic renal failure; and in patients with coagulase-negative staphylococcal infection and abscess. Another characteristic symptom is chills, which occurs in 42%-75% of cases.
  • Other signs and symptoms include the following:
    • Anorexia
    • Weight loss
    • Malaise
    • Dyspnea
    • Cough
    • Stroke
    • Headache
    • Nausea/vomiting
    • Myalgia
    • Arthralgia
    • Chest pain
    • Abdominal pain
    • Back pain
    • Confusion
    • Sweats
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Physical

Physical examination findings commonly encountered in myocardial abscess are mainly due to the underlying infective endocarditis. These include the following:

  • Fever
  • Tachycardia
  • Murmur, especially changing or new murmur
  • Neurological abnormalities
  • Embolic event
  • Splenomegaly
  • Clubbing
  • Peripheral manifestations
  • Osler nodes
  • Splinter hemorrhages
  • Petechiae
  • Janeway lesions
  • Retinal lesions (Roth spots)
  • Widening pulse pressure, especially with involvement of the aortic valve and progression of aortic regurgitation
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Causes

Causes of myocardial abscess may include the following:

  • Associated with endocarditis
    • Native valve endocarditis
    • Prosthetic valve endocarditis - Bioprosthesis, mechanical prosthesis
    • Myocardial (muscle) infection - Ventricular septal wall, left ventricular posterior wall
  • Associated with septicemia
    • Bronchopneumonias
    • Genitourinary infections
    • Other infections
  • Miscellaneous
    • Complications of acute MI
    • Trauma and deep penetrating wounds
    • Mechanical interventions - Catheterization, angioplasty, stent
    • Infection associated with left ventricular aneurysm
    • Infection associated with atrial myxoma (exceedingly rare)
    • Myocarditis and suppuration associated with HIV
    • Transplanted heart infection
    • Asymptomatic
    • Other
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Contributor Information and Disclosures
Author

Vibhuti N Singh, MD, MPH, FACC, FSCAI  Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine

Vibhuti N Singh, MD, MPH, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Florida Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kul Aggarwal, MD, FACC  Professor of Clinical Medicine, Department of Internal Medicine, Division of Cardiology, University of Missouri-Columbia School of Medicine; Chief, Cardiology Section, Harry S Truman Veterans Hospital

Kul Aggarwal, MD, FACC is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Rakesh K Sharma, MD, FACC  Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas

Rakesh K Sharma, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of International Physicians, American College of Physicians, American Heart Association, and American Medical Association

Disclosure: Nothing to disclose.

Jamshid Shirani, MD  Director of Cardiology Fellowship Program, Director of Echocardiography Laboratory, St Luke's Hospital and Health Network

Jamshid Shirani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Echocardiography, and Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Joel A Strom, MD, ME  Adjunct Clinical Professor of Medicine, University of Florida College of Medicine

Joel A Strom, MD, ME is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American Heart Association, and American Society of Echocardiography

Disclosure: Merck, Inc. Own stock None; Abbott Labs, Inc. own stock None; Medtronic own stock None; General Electric own stock None; Pfizer, Inc. own stock Other

Mingquan Suksanong  Clinical Assistant Professor, Department of Medicine, Division of Infectious Diseases and Tropical Medicine, University of South Florida College of Medicine; Consulting Staff, Department of Medicine, Bayfront Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Craig T Basson, MD, PhD  Gladys and Roland Harriman Professor of Medicine, Director of the Center for Molecular Cardiology, Director of Cardiovascular Research, Division of Cardiology, Department of Medicine, Weill Cornell Medical College; Attending Physician, New York Presbyterian Hospital

Craig T Basson, MD, PhD is a member of the following medical societies: American College of Cardiology and American Heart Association

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

John L Brusch, MD, FACP  Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Myocardial abscess. Transesophageal echocardiogram exhibiting aortic valvular endocarditis and aortic root abscess.
Myocardial abscess. Complete heart block seen on a 12-lead electrocardiogram in a patient with myocardial abscess involving the prosthetic aortic valve ring.
Myocardial abscess. Color Doppler imaging showing flow into the aortic root abscess.
Myocardial abscess. Aortic valvular ring abscess seen by transesophageal echocardiography.
Myocardial abscess (gross).
Myocardial abscess (opened).
 
 
 
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