Chapter 7 : Viral Myocarditis

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Myocarditis is an inflammatory process affecting the heart and causing ventricular dysfunction. In childhood, myocarditis is usually an acute process with left ventricular (LV) systolic dysfunction with or without dilation of the LV, while adult presentation is most typically chronic and mimics dilated cardiomyopathy (DCM) with LV dilation and systolic dysfunction or LV dysfunction without dilation. Usually sporadic, viral myocarditis can also occur as an epidemic. Viral infection triggers interstitial inflammation or myocardial injury, resulting in cardiac enlargement and an increase in the ventricular end-diastolic volume. Normally, this increase in volume results in an increased force of contraction, improved ejection fraction, and improved cardiac output as described by the Starling mechanism. In cases of chronic myocarditis, the valves may be glistening white, suggesting that endocardial fibroelastosis (EFE) may be the result of an in utero viral myocarditis. At the time of initial biopsy, a specimen may be classified as active myocarditis, borderline myocarditis, or no myocarditis, depending on whether an inflammatory infiltrate occurs in association with myocyte degeneration or necrosis (active) or too sparse of an infiltrate or no myocyte degeneration occurs (borderline). The current strategy for therapy includes supporting the blood pressure to achieve end-organ perfusion and urine output without "driving" the myocardium with inotropic agents.

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Image of FIGURE 1

Endomyocardial biopsy histology demonstrates lymphocytic infiltrates, myocardial edema, and necrosis.

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Image of FIGURE 2

Electrocardiogram from a child with myocarditis. Sinus tachycardia and low-voltage QRS complexes with inverted T waves and a pattern of myocardial infarction with wide Q waves in leads I and aVL, and ST-segment changes consistent with ischemia, are noted throughout.

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Image of FIGURE 3

Endomyocardial biopsy technique. The bioptome is advanced via the superior vena cava into the right atrium, across the tricuspid valve into the right ventricle, and finally situated against the interventricular septum, where the biopsy is performed. The bioptome can also be advanced via the inferior vena cava with similar results. (Reprinted from reference with permission of Elsevier.)

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Image of FIGURE 4

Nested PCR for the adenovirus genome. The agarose gel demonstrates a 308-bp PCR-positive band in the adenovirus-positive control lane, as well as in lanes designated MP, AD, BS, and JW, in which DNA was extracted from myocardial tissue samples obtained from patients with myocarditis. Patients designated LS and JH are PCR negative, as is the negative (–) control lane. MW, molecular weight.

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Image of FIGURE 5

PCR analysis of fixed heart samples obtained from infants with EFE. Note the PCR-positive bands at 223 bp indicative of mumps virus. Sequence analysis confirmed the viral genome as that consistent with mumps.

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Viral causes of myocarditis

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7
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Myocarditis etiologies in children by PCR analysis

Citation: Towbin J. 2009. Viral Myocarditis, p 97-107. In Richman D, Whitley R, Hayden F (ed), Clinical Virology, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555815981.ch7

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