eMedicine Specialties > Infectious Diseases > Cardiovascular and Intravascular Infections

Myocardial Abscess: Differential Diagnoses & Workup

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
Coauthor(s): Kul Aggarwal, MD, FACC, Professor of Clinical Medicine, Department of Internal Medicine, Division of Cardiology, University of Missouri School of Medicine; Chief, Cardiology Section, Harry S Truman Veterans Hospital; Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas; Jamshid Shirani, MD, FACC, FAHA, Consulting Staff, Director of Cardiovascular Fellowship Program, Department of Medicine, Division of Cardiology, Geisinger Medical Center; Joel A Strom, MD, ME, Professor of Internal Medicine, Chemical and Biomedical Engineering, and Honors College, University of South Florida; Mingquan Suksanong, MD, Clinical Assistant Professor, Department of Medicine, Division of Infectious Diseases and Tropical Medicine, University of South Florida School of Medicine; Consulting Staff, Department of Medicine, Bayfront Medical Center
Contributor Information and Disclosures

Updated: Aug 27, 2009

Differential Diagnoses

Acute Rheumatic Fever
Myocardial Infarction
Aortic Regurgitation
Myocardial Rupture
Atrioventricular Dissociation
Penetrating Chest Trauma
Cardiogenic Shock
Pulmonary Edema, Cardiogenic
Enterobacter Infections
Second-Degree Atrioventricular Block
Enterococcal Infections
Septic Shock
Fever of Unknown Origin
Staphylococcal Infections
First-Degree Atrioventricular Block
Streptococcus Group A Infections
Heart Transplantation
Streptococcus Group B Infections
Heart-Lung Transplantation
Streptococcus Group D Infections
Infections After Transplantation
Sudden Cardiac Death
Infective Endocarditis
Third-Degree Atrioventricular Block
Mitral Regurgitation

Workup

Laboratory Studies

  • Routine blood tests
    • Complete blood cell count findings (ie, hematological parameters) commonly are abnormal.
      • Anemia with normochromic normocytic red cell indices is present. A low serum iron level is also observed. A low serum iron-binding capacity is observed in 70-90% of patients.
      • Anemia worsens with increased duration of illness.
      • In subacute endocarditis, the white blood cell count is usually normal. In contrast, a leukocytosis with increased segmented granulocytes is common in acute endocarditis and myocardial abscess.
      • Thrombocytopenia occurs only rarely.
    • Perform a metabolic chemistry panel.
  • Erythrocyte sedimentation rate
    • The erythrocyte sedimentation rate (ESR) is elevated (on average approximately 55 mm/h) in almost all patients with endocarditis and myocardial abscess; the exceptions are those with CHF, renal failure, or disseminated intravascular coagulation.
    • Although the results are nonspecific, the absence of an increased ESR, other than in the selected circumstances already mentioned, is evidence against a diagnosis of endocardial or myocardial infection or abscess.
  • Blood cultures: Blood cultures are the crucial laboratory tests for confirming the diagnosis of the underlying endocarditis.
  • Urinalysis
    • Urinalysis results are often abnormal, even when renal function remains normal.
    • Proteinuria and microscopic hematuria are noted in 50% of patients.
    • Urinalysis also plays a standard role in the evaluation of azotemia, which is frequently associated with myocardial abscess.
  • Other tests: Perform these as needed for the assessment of the primary source of bacteremia.

Imaging Studies

In the past, most cases of myocardial abscess were found during autopsy; however, detection of myocardial abscess can now be achieved antemortem using multiple diagnostic modalities. Many of these are noninvasive, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), indium In 111 radionuclide scintigraphy, computed tomography (CT) scan, and magnetic resonance imaging (MRI).

  • Chest radiography
    • Perform chest radiography to look for associated pulmonary sepsis.
    • Chest radiographic findings help assess for CHF.
  • Transthoracic echocardiography
    • TTE helps evaluate patients in whom endocarditis or myocardial abscess is suggested clinically. Findings frequently allow the morphologic confirmation of infection and increasingly aid in making decisions regarding management.
    • One must perform an echocardiographic evaluation in all patients, including those with negative blood culture findings.
    • TTE has a sensitivity of 23% and specificity of 98.6%.
    • According to Ellis et al (1985), the following 5 criteria are 86% sensitive and 88% specific for myocardial abscess:12
      • Evidence of prosthetic valve rocking
      • Aneurysmal dilatation of the sinus of Valsalva
      • Posterior aortic root thickness greater than 10 mm
      • Perivalvular density in the septum of greater than 14 mm
      • The presence of "echo-free space" - Very specific but found relatively infrequently
  • Transesophageal echocardiography
    • Although many patients with NVE involving the aortic or mitral valve can be adequately assessed using TTE, TEE with color flow and continuous pulsed Doppler is the state-of-the-art technique. Doppler and color-flow Doppler or contrast 2-dimensional echocardiography helps optimally define fistulas and abscess pockets and extensions.

      Myocardial abscess. Color Doppler imaging showing...

      Myocardial abscess. Color Doppler imaging showing flow into the aortic root abscess.

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      Myocardial abscess. Color Doppler imaging showing...

      Myocardial abscess. Color Doppler imaging showing flow into the aortic root abscess.

    • TEE has a sensitivity of 87% and specificity of 94.6%. Patients in whom an abscess is suggested but has not been detected using TEE should undergo MRI, including magnetic resonance angiography.

      Myocardial abscess. Transesophageal echocardiogra...

      Myocardial abscess. Transesophageal echocardiogram exhibiting aortic valvular endocarditis and aortic root abscess.

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      Myocardial abscess. Transesophageal echocardiogra...

      Myocardial abscess. Transesophageal echocardiogram exhibiting aortic valvular endocarditis and aortic root abscess.



      Myocardial abscess. Aortic valvular ring abscess ...

      Myocardial abscess. Aortic valvular ring abscess seen by transesophageal echocardiography.

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      Myocardial abscess. Aortic valvular ring abscess ...

      Myocardial abscess. Aortic valvular ring abscess seen by transesophageal echocardiography.

  • Scintigraphy
    • Indium In 111 leukocyte scintigraphy is especially useful in prosthetic valve endocarditis, in which echocardiography shows too much scatter.
    • A few milliliters of venous blood is drawn and mixed with an anticoagulant solution. The white blood cells are separated and labeled with radioactive isotope111 In, centrifuged, resuspended in isotonic sodium chloride solution, and reinjected into the patient. Images are then obtained with a gamma-ray camera within 16-24 hours. The viable radioactive leukocytes potentially accumulate in the areas of inflammation or abscess. Obtain oblique views to avoid overshadowing by sternal accumulation.
    • The need for111 In scintigraphy is very low if TEE is used.
  • MRI: This is a good modality for helping delineate myocardial abscess. However, the portability and excellent resolution of echocardiography make it more practical than MRI.
  • CT scan: Only anecdotal reports of diagnosis are available. It is not very sensitive.
  • Intraoperative echocardiography: Although invasive, small abscesses can be detected in the operating room by means of intraoperative echocardiography, which may enable the operating surgeon to drain the abscess effectively.

Other Tests

  • Electrocardiography
    • New-onset and persistent electrocardiographic conduction abnormalities may be observed. Gradual PR prolongation may be observed, and it may suggest development of valve ring abscess.
    • Although not a sensitive indicator of perivalvular infection or abscess (28%), these findings are relatively specific (85-90%).

      Myocardial abscess. Complete heart block seen on ...

      Myocardial abscess. Complete heart block seen on a 12-lead electrocardiogram in a patient with myocardial abscess involving the prosthetic aortic valve ring.

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      Myocardial abscess. Complete heart block seen on ...

      Myocardial abscess. Complete heart block seen on a 12-lead electrocardiogram in a patient with myocardial abscess involving the prosthetic aortic valve ring.

  • Tests of immune system stimulation
    • Tests results may show disease activity, but the tests are costly and not very efficient for diagnosis or monitoring response to therapy
    • These may include testing of circulating immune complexes, rheumatoid factor, quantitative immune globulin, cryoglobulins, and C-reactive protein.
  • Serologic tests
    • Serological test findings are used to evaluate cardiac sepsis in which blood culture findings are negative.
    • Tests to detect antibodies to ribitol teichoic acids from staphylococci may help distinguish uncomplicated S aureus bacteremia from that associated with cardiac involvement.
    • These tests have not been used in clinical applications because of their lack of adequate specificity or predictive value.

Procedures

  • Cardiac catheterization may add very little to the imaging studies and is not recommended unless coronary angiography is needed for patients undergoing valve surgery who also may have significant coronary artery disease.

Histologic Findings

Biopsy and histologic assessment is not a part of the diagnostic workup of myocardial abscess. However, surgically removed valves and autopsy findings from fatal cases reveal certain gross and microscopic features.

Myocardial abscess (gross).

Myocardial abscess (gross).

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Myocardial abscess (gross).

Myocardial abscess (gross).



Myocardial abscess (opened).

Myocardial abscess (opened).

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Myocardial abscess (opened).

Myocardial abscess (opened).

The infection in native valves and mechanical prostheses that leads to development of myocardial abscess tends to extend beyond the valve ring into the annulus and periannular tissue and into the mitral-aortic intravalvular fibrosa, resulting in ring abscesses, septal abscesses, fistulous tracts, and dehiscence of the prosthesis with hemodynamically significant paravalvular regurgitation.

In autopsy experience with 74 patients, annular invasion was noted in 85%, myocardial abscess formation in 32%, valve obstruction by vegetation overgrowth in 19%, and erosion through the aortic annulus to cause pericarditis in 5%. In another series of 85 patients, the findings were annulus invasion in 42%, myocardial abscess in 14%, valve obstruction in 4%, and pericarditis in 2%. The intracardiac pathology of bioprosthetic valve infective endocarditis is more heterogeneous and includes invasive disease and leaflet destruction.

Myocardial abscess histology findings demonstrate damaged cardiac tissue with degraded collagen and polymorphonuclear predominance.

More on Myocardial Abscess

Overview: Myocardial Abscess
Differential Diagnoses & Workup: Myocardial Abscess
Treatment & Medication: Myocardial Abscess
Follow-up: Myocardial Abscess
Multimedia: Myocardial Abscess
References
Further Reading
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Keywords

myocardial abscess, myocardial sepsis, cardiac abscess, bacterial endocarditis, infective endocarditis, IE, endocardial abscess, suppurative endocarditis, infectious myocarditis, heart infection, heart valve infection, valve infection, prosthetic valve infection, perivalvular infection, cardiac conduction system infection

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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 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, FACC, FAHA, Consulting Staff, Director of Cardiovascular Fellowship Program, Department of Medicine, Division of Cardiology, Geisinger Medical Center
Jamshid Shirani, MD, FACC, FAHA 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, Professor of Internal Medicine, Chemical and Biomedical Engineering, and Honors College, University of South Florida
Joel A Strom, MD, ME is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, and Sigma Xi
Disclosure: Merck, Inc. Own stock None; Abbott Labs, Inc. own stock None; Medtronic own stock None; General Electric own stock None

Mingquan Suksanong, MD, Clinical Assistant Professor, Department of Medicine, Division of Infectious Diseases and Tropical Medicine, University of South Florida School of Medicine; Consulting Staff, Department of Medicine, Bayfront Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Craig T Basson, MD, PhD, FAHA, FACC, Gladys and Roland Harriman Professor of Medicine, Weill Cornell Medical College; Director, Cardiovascular Research, Greenberg Division of Cardiology, Department of Medicine, The New York Presbyterian Hospital
Craig T Basson, MD, PhD, FAHA, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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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