myocarditis, pericarditis, and cardiac tumors

inflammation of the heart muscle with myocyte necrosis. Must not be caused by ischemic heart disease (MI)

myocarditis

the most common etiology of myocarditis is ____, but others are (6)

most common viruses

others: bacteria, fungi, parasites, cardiotoxins, drugs, and systemic autoimmune disorders

epidemiology of myocarditis:

death rate is the highest when?

after age 15, the death rate is higher in ___ than __

disability from myocarditis is largely due to ___

highest at 1st year

men more than women

heart failure

_____ symptoms range from asymptomatic to sudden death, may mimic acute MI

myocarditis

a late complication of myocarditis is ____

dilated cardiomyopathy

What is the gold standard for diagnosis of myocarditis?

endomyocardial biopsy

To distinguish myocarditis from acute coronary syndrome, what do we use?

CRP/troponin ratio

higher in myocarditis and lower in ACS

Which clinical classification of myocarditis?

2-4 weeks after exposure

increased risk of dilated cardiomyopathy (worse prognosis)

3rd heart sound can be heard

acute

Which clinical classification of myocarditis?

occurs usually within 2 weeks after exposure

profound left ventricular dysfunction

either die within 2 weeks or fully recover

fulminant

Which clinical classification of myocarditis?

symptoms >2 weeks

moderate ventricular dysfunction

ongoing inflammation and fibrosis; develops restrictive cardiomyopathy

chronic active

Which clinical classification of myocarditis?

persistent histologic infiltrate, often with foci of myocyte necrosis

no ventricular dysfunction

chronic persistent

What virus is the most common cause of myocarditis?

enteroviruses: mainly Coxsackie B virus (Parvo B-19 and HHV-6 are others)

How can we identify the causative virus for viral myocarditis?

serologic studies or viral nucleic acid sequences in myocardial biopsy

What are the two ways a virus can damage the myocardium? (viral myocarditis)

direct cytopathic effects of the virus and immune response to the virus

What are the 2 most common bacterial agents with bacterial myocarditis?

Borrelia burgdorferi (Lyme carditis)

• AV block

Chorynebacterium diptheriae

Fungal myocarditis is rare… so when is it mostly seen?

immunocompromised pts

What are the most common fungal agents of fungal myocarditis?

Candida and Apergillus

What is the most common parasitic agent for parasitic myocarditis?

Trypanosoma Cruzi (Chagas disease)

If we see a pt with myocarditis, and we see latin america (travel), pseudocyst dilations, cardiomegaly, megaesophagus, and megacolon, what are we thinking?

parasitic myocarditis: Trypanosoma cruzi (Chagas disease)

If we see myocarditis with Aschoff body formation, Anitschkow cells (caterpillar cells) and post-strep infection, what are we thinking?

immune mediated myocarditis likely from rheumatic fever

What are some of the direct cardiotoxins that can cause myocarditis? (7)

don’t necessarily memorize, just be familiar

Anthracyclines (doxorubicin), cocaine, alcohol, arsenic, cyclophosphamide, radiation, and heavy metals

what disease involves the sac like structure surrounding the heart

can occur with direct disease of the heart or indirectly through systemic disease (like SLE)

pericardial disease

What is distention of the pericardium from:

excess serous fluid (___)

accumulation of blood (_____)

build up of pus (_____)

accumulation of lymphatic fluid (____)

pericardial effusion

hemopericardium

purulent pericarditis

chylous effusion

explain the difference between chronic and acute accumulation of fluid with pericardial effusion

chronic: happens slowly so pericardium can remodel

• cardiac function maintains; sometimes only sign is water bottle config on xray

acute: clinically devastating

• notably from hemopericardium (ruptured MI or aortic dissection) leading to cardiac tamponade

Which pericarditis is produced by noninfectious inflammatory diseases (rheumatic fever, SLE, rheumatoid arthritis, scleroderma, etc.) 

serous pericarditis

What pericarditis is most common, serous fluid with fibrinous exudate

serofibrinous/fibrinous pericarditis

What pericarditis?

“bread and butter” macroscopically

Dressler syndrome

pericardial friction rub

serofibrinous/fibrinous pericarditis

What is: active infection in the pericardial space; could be direct extension from neighboring infections, travel through the blood or lymphatics

purulent/suppurative pericarditis

Hemorrhagic pericarditis is obviously blood filled, what is the most common cause?

spread of malignancy to the pericardial space

what pericarditis?

pericardial tap often reveals neoplastic cells

hemorrhagic pericarditis

With chronic/healed pericarditis, mostly cardiac function ___

is preserved

What is:

adhesions of the external aspect of the parietal layer that strains cardiac function

clinically: can see systolic retraction of rib cage and diaphragm and pulsus paradoxus

adhesive mediatinopericarditis (chronic)

What is:

heart encased in dense, fibrous or fibrocalcific scar that limits diastolic expansion and cardiac output

can mimic restrictive cardiomyopathy

constrictive pericarditis (chronic)

What is the most common primary cardiac tumor?

myxomas

What tumor?

Carney complex

thought to arise from multipotent mesenchymal stem cells

myxomas

What tumor?

most common in left atrium

myxomas

what tumor?

most common in left ventricle

cardiac fibroma

what tumor?

associated with nevoid basal-cell carcinoma syndrome

cardiac fibroma

What tumor?

typically in left ventricle or right atrium

cardiac lipomas

What tumor?

forms on valves

may embolize

may also include coronary artery orifices

papillary fibroelastoma

What tumor?

sea anemone appearance

papillary fibroelastoma

What tumor?

most common primary childhood tumor

associated with tuberous sclerosis

cardiac rhabdomyomas

What tumor?

histology: spider cells

many regress spontaneously over time

cardiac rhabdomyomas

____ are the most common type of cardiac sarcoma

angiosarcomas

what is the most likely cancer to metastasize?

malignant melanoma