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10-42: Infectious Myocarditis

Todd Kiefer; Christopher B. Granger; Kevin P. Jackson

Key Clinical Updates in Infectious Myocarditis

Myocarditis following infection with SARS-CoV-2 infection and following vaccination have been reported in the medical literature. In both scenarios, younger male patients seem to be at highest risk for this overall rare event.

Boehmer TK et al. MMWR Morb Mortal Wkly Rep. [PMID: 34473684]

Witberg G et al. N Engl J Med. [PMID: 34614329]

ESSENTIALS OF DIAGNOSIS

  • Often follows an upper respiratory infection.

  • May present with chest pain (pleuritic or nonspecific) or signs of heart failure.

  • Echocardiogram documents cardiomegaly and contractile dysfunction. Initial heart size is generally normal with thickened walls.

  • Myocardial biopsy, though not sensitive, may reveal a characteristic inflammatory pattern. MRI has a role in diagnosis.

  • COVID-19 myocarditis impacts between 3% and 58% of people with COVID-19 based on underlying myocardial risk and imaging.

GENERAL CONSIDERATIONS

Cardiac dysfunction due to primary myocarditis is presumably caused by either an acute viral infection or a post viral immune response. Secondary myocarditis is the result of inflammation caused by nonviral pathogens, medications, chemicals, physical agents, or inflammatory diseases (such as SLE). The list of both infectious and noninfectious causes of myocarditis is extensive (Table 10–13).

Table 10–13.Causes of myocarditis.
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Table 10–13. Causes of myocarditis.

1. INFECTIOUS CAUSES

 RNA viruses: Picornaviruses (coxsackie A and B, echovirus, poliovirus, hepatitis virus), orthomyxovirus (influenza), paramyxoviruses (respiratory syncytial virus, mumps), togaviruses (rubella), flaviviruses (dengue fever, yellow fever), SARS-CoV-2

 DNA viruses: Adenovirus (A1, 2, 3, and 5), erythrovirus (Bi9V and 2), herpesviruses (human herpes virus 6 A and B, cytomegalovirus, Epstein-Barr virus, varicella-zoster), retrovirus (HIV)

 Bacteria: Chlamydia (Chlamydophila pneumoniae, C psittaci), Haemophilus influenzae, Legionella, Pneumophilia, Brucella, Clostridium, Francisella tularensis, Neisseria meningitis, Mycobacterium (tuberculosis), Salmonella, Staphylococcus, streptococcus A, Streptococcus pneumoniae, tularemia, tetanus, syphilis, Vibrio cholerae

 Spirocheta: Borrelia recurrentis, leptospira, Treponema pallidum

 Rickettsia: Coxiella burnetii, R rickettsii, R prowazekii

 Fungi: Actinomyces, Aspergillus, Candida, Cryptococcus, Histoplasma, Nocardia

 Protozoa: Entamoeba histolytica, Plasmodium falciparum, Trypanosoma cruzi, T burcei, T gondii, Leishmania

 Helminthic: Ascaris, Echinococcus granulosus, Schistosoma, Trichenella spiralis, Wuchereria bancrofti

2. NONINFECTIOUS CAUSES

 Autoimmune diseases: Dermatomyositis, inflammatory bowel disease, rheumatoid arthritis, Sjögren syndrome, SLE, granulomatosis with polyangiitis, giant cell myocarditis

 Medications: Aminophylline, amphetamine, anthracyclin, catecholamines, chloramphenicol, cocaine, cyclophosphamide, doxorubicin, 5-FU, mesylate, methysergide, phenytoin, trastuzumab, zidovudine

 Hypersensitivity reactions due to medications: Azithromycin, benzodiazepines, clozapine, cephalosporins, dapsone, dobutamine, lithium, diuretics, thiazide, methyldopa, mexiletine, streptomycin, sulfonamides, NSAIDs, tetanus toxoid, tetracycline, tricyclic antidepressants

 Hypersensitivity reactions due to venoms: Bee, wasp, black widow spider, scorpion, snake

 Systemic diseases: Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome), collagen diseases, sarcoidosis, Kawasaki disease, systemic sclerosis

 Other: Heat stroke, hypothermia, transplant rejection, radiation injury

Schultheiss HP et al. The manage of myocarditis. Eur Heart J. 2011;32(21):2616–25, by permission of Oxford University Press and the European Society of Cardiology.

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