Myocardial Abscess Clinical Presentation

Updated: Jan 28, 2015
  • Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Presentation

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 and alteration of heart sounds and murmurs (eg, new-onset valvular regurgitation [100% of cases]) [11]
  • Poor response to antibiotics, with persistent fever and other signs of infection despite adequate antibiotic coverage
  • 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 mechanical)
  • Right-sided endocarditis in patients with congenital heart disease

The duration of symptoms is short.

The infecting organism is a Pneumococcus or Staphylococcus species.

Acute MI occurs in the setting of septicemia.

Sepsis may complicate 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 associated with endocarditis may include the following:

  • Native valve endocarditis
  • Prosthetic valve endocarditis - Bioprosthesis, mechanical prosthesis
  • Myocardial (muscle) infection - Ventricular septal wall, left ventricular posterior wall

Causes of myocardial abscess associated with septicemia may include the following:

  • Bronchopneumonias
  • Genitourinary infections
  • Other infections

Miscellaneous causes of myocardial abscess may include the following:

  • 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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