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Pediatric Nonviral Myocarditis Workup

  • Author: Stuart Berger, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Mar 30, 2015
 

Approach Considerations

Echocardiography

Echocardiography is critical in diagnosing myocarditis. Typically, the presence of diminished ventricular function with dilation of 1 or several chambers of the heart becomes obvious. Echocardiography rules out pericardial effusion or structural congenital heart disease as the etiology of the symptoms.

Electrocardiography

Sinus tachycardia out of proportion to the degree of fever may be noticeable in patients with myocarditis. Arrhythmias, including ST-T wave changes in as many as 80% of patients, may be associated with myocarditis. These changes may be sensitive indicators of myocardial ischemia, or they may be nonspecific findings.

Histologic findings

The major purposes of a tissue biopsy are to establish a diagnosis of myocarditis and to classify the stage of disease as acute, healed, or chronic. The specific histologic findings differ based on the particular etiologic agent associated with myocarditis.

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Endomyocardial Biopsy

The role of endomyocardial biopsy in the diagnosis of myocarditis remains controversial. Biopsy may present somewhat of a risk in the acutely ill and unstable patient, and histologic diagnosis may not be easy.

Typical sampling usually includes small areas of the right ventricle. Because myocarditis may be focal and may primarily involve the left ventricle, results of the sampling techniques used may not fully represent the true incidence of myocarditis. In other words, a negative biopsy result does not rule out myocarditis.

A major problem with endomyocardial biopsy is the possibility of overinterpretation or misinterpretation of the biopsy specimen. In addition, clinicians argue that the results of endomyocardial biopsy may not change the treatment of myocarditis. This may be true, at least until a clearer role emerges for immunosuppression therapy in patients with this disease. Little work in pediatric patients has been done in this area.

The high-contrast and high-resolution fluorescent imaging of confocal laser scanning microscopy and super-resolution microscopy may potentially increase the diagnostic yield of endomyocardial biopsy.[6] These modalities appear to provide improved quantitative digital analysis and may thereby improve precision and accuracy in the evaluation of critical pathologic features.[6]

Performing a biopsy to establish a subset of pediatric patients with active myocarditis may be useful in order to study different therapies in a controlled, prospective manner.

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Contributor Information and Disclosures
Author

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Ameeta Martin, MD Clinical Associate Professor, Department of Pediatric Cardiology, University of Nebraska College of Medicine

Ameeta Martin, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Allen Towbin, MD, MSc FAAP, FACC, FAHA, Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, Texas Pediatric Society, Cardiac Electrophysiology Society

Disclosure: Nothing to disclose.

References
  1. Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis. 2010 Jan-Feb. 52(4):274-88. [Medline].

  2. Shamna RB, Lalitha AV, Lini B. Myocarditis in Children. Indian J Pediatr. 2013 Sep 26. [Medline].

  3. Libman E, Sacks B. A hitherto undescribed form of valvular and mural endocarditis. Arch Intern Med. 1974. 33:701-37.

  4. Klugman D, Berger JT, Sable CA, et al. Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol. 2010 Feb. 31(2):222-8. [Medline].

  5. Sachdeva S, Song X, Dham N, Heath DM, DeBiasi RL. Analysis of clinical parameters and cardiac magnetic resonance imaging as predictors of outcome in pediatric myocarditis. Am J Cardiol. 2015 Feb 15. 115(4):499-504. [Medline].

  6. Crossman DJ, Ruygrok PN, Hou YF, Soeller C. Next-generation endomyocardial biopsy: the potential of confocal and super-resolution microscopy. Heart Fail Rev. 2015 Mar. 20(2):203-14. [Medline].

  7. [Guideline] Heart Failure Society Of America. Myocarditis: Current treatment. J Card Fail. 2006 Feb. 12(1):e120-2. [Medline].

  8. Frustaci A, Pieroni M, Chimenti C. Immunosuppressive treatment of chronic non-viral myocarditis. Ernst Schering Res Found Workshop. 2006. 343-51. [Medline].

  9. Miller JR, Lancaster TS, Eghtesady P. Current approaches to device implantation in pediatric and congenital heart disease patients. Expert Rev Cardiovasc Ther. 2015 Apr. 13(4):417-27. [Medline].

 
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Myocarditis with scarring, autopsy. The image is a short axis gross photograph of an 8-year-old child with clinical myocarditis showing scarring of both ventricles, more prominent in the left. The fibrosis shows a random distribution with epicardial, myocardium, and pericardial involvements.
 
 
 
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