MYOCARDITIS AND PERICARDITIS

Transcription

1 MYOCARDITIS AND PERICARDITIS Dr.Mahmoud Abbad Pediatric Cardiology Al-Bashir Hospital

2 MYOCARDITIS Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations, from subtle to devastating Pathology: -Grossly: inflamed myocardium is soft, flabby and pale with areas with scarring -Macroscopically: Patchy infiltrations by plasma cells, mononuclear leukocytes, and giant cell infiltration in the later stages.

3 CAUSES Viruses are the most common causes of myocarditis; Adenovirus, Coxacivirus B, and Echoviruses are the most common agents. Bacteria, Rickettsia, Fungi, Parasites and Protozoa rarely cause myocarditis Immune mediated disease, rheumatic fever and Kawasaki disease maybe a cause Collagen vascular disease Toxic myocarditis (drug ingestion, diphtheria toxin)

4 CLINICAL MANIFESTATION Hx - may have hx of an upper respiratory tract infection - sudden onset of anorexia, vomiting, lethargy and circulatory shock in newborn and small infants Physical examination - the presentation depends on the patient s age and the acute or chronic nature of the infection - in neonates and infants signs of CHF (tachycardia, gallop rhythm, tachypnea and cyanosis - in older children a gradual onset of CHF and arrhythmias are commonly seen - soft systolic heart murmur and irregular rhythm

5 Investigations - ECG: low QRS voltage, ST-T changes, PR prolongation, prolonged QT interval - CXR: cardiomegaly - ECHO: cardiac enlargement and impaired LV function - laboratory: Troponin level and myocardial enzymes maybe elevated - Endomyocardial biopsy can confirm myocarditis

6 PROGNOSIS Mortality rate is high in neonates 75% The majority of patients with mild inflammation recover completely Some patients develop subacute or chronic myocarditis with persistent cardiomegaly

7 MANAGEMENT Bed rest and limitation in activities during the acute phase Antifailure measures (diuretics, inotropic agents such as dopamine in critically ill patients) Digoxin may be given cautiously because some patients with myocarditis are very sensitive to the drug ACE inhibitors High dose Gammaglobulin shows beneficial effects Treatment of arrhythmias if present

8 PERICARDITIS Pericarditis is the inflammation of the parietal and visceral surfaces of the pericardium. Causes: - Viral infection is the most common cause - acute rheumatic fever - bacterial infection (i.e purulent pericarditis) (rare but serious) (S.Aurious, Streppnuemonia, Hemophilus influanzea) - TB - Post heart surgery (postpericardiotomy syndrome) - Collagen disease - Oncologic disease or its therapy - Uremia

9 Pericardial effusion maybe serofibrinous, hemorrhagic or purulent Effusion maybe completely absorbed or may result in pericardial thickening or chronic constriction ( constrictive pericarditis )

10 CLINICAL MANIFESTATIONS Hx: - History of upper respiratory tract infections - Pericordial pain (dull, itching or stabbing) with radiation to the shoulder and neck - Fever Physical examination - Pericardial friction rub: is the cardinal physical sign - Distant heart sound - Pulsus paradoxus: pericardial effusion with tamponade - Murmus is usually absent - Fever, tachycardia, chest pain and dyspnea are almost always present with purulent pericarditis

11 Investigations: - ECG: low voltage QRS complex, initially ST-segment elevation, T-inversion after 2-4 weeks - CXR: - Cardiomegaly - Water bottle shaped heart is characteristic of a large effusion - Increased pulmonary vascular markings - ECHO: diagnostic for pericardial effusion and detecting Tamponade

12 Initial ST elevations Water bottle sign

13 CARDIAC TAMPONADE Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary edema, shock, and death

14 Signs of cardiac tamponade - Distant heart sounds - Tachycardia - Hypotension - pulsus paradoxus - venous distention - hepatomegaly

15 MANAGEMENT OF PERICARDITIS Pericardiocentesis to identify the cause specially when purulent or tuberculous pericarditis is suspected Urgent decompression by pericardiocentesis for cardiac tamponade Urgent surgical drainage and iv antibiotics for purulent pericarditis No specific treatment for viral pericarditis Specific treatment of basic disease (uremia, collagen disease) Corticosteroids are indicated in severe rheumatic carditis or postpericardiotomy syndrome Salicylates for non-bacterial or rheumatic pericarditis

16 THANK YOU