Excerpt for Inflamed Heart, (Myocarditis) A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions by , available in its entirety at Smashwords

Inflamed Heart,






The Condition,




Related Conditions


Dr Kenneth Kee

M.B.,B.S. (Singapore)

Ph.D (Healthcare Administration)

Copyright Kenneth Kee 2018 Smashwords Edition

Published by Kenneth Kee at


This book is dedicated

To my wife Dorothy

And my children

Carolyn, Grace

And Kelvin

This book describes Inflamed Heart (Myocarditis), Diagnosis and Treatment and Related Diseases which is seen in some of my patients in my Family Clinic.

(What The patient Need to Treat Inflamed Heart)

This eBook is licensed for your personal enjoyment only. This eBook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each reader.

If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to and purchase your own copy.

Thank you for respecting the hard work of this author.


I have been writing medical articles for my blog (A Simple Guide to Medical Disorder) for the benefit of my patients since 2007.

My purpose in writing these simple guides was for the health education of my patients.

Health Education was also my dissertation for my Ph.D (Healthcare Administration).

I then wrote an autobiolographical account of his journey as a medical student to family doctor on his other blog

This autobiolographical account “A Family Doctor’s Tale” was combined with my early “A Simple Guide to Medical Disorders” into a new Wordpress Blog “A Family Doctor’s Tale” on

From which many free articles from the blog was taken and put together into 800 eBooks.

Some people have complained that the simple guides are too simple.

For their information they are made simple in order to educate the patients.

The later books go into more details of medical disorders.

The first chapter is always from my earlier blogs which unfortunately tends to have typos and spelling mistakes.

Since 2013, I have tried to improve my spelling and writing.

As I tried to bring the patient the latest information about a disorder or illness by reading the latest journals both online and offline, I find that I am learning more and improving on my own medical knowledge in diagnosis and treatment for my patients.

Just by writing all these simple guides I find that I have learned a lot from your reviews (good or bad), criticism and advice.

I am sorry for the repetitions in these simple guides as the second chapters onwards have new information as compared to my first chapter taken from my blog.

I also find repetition definitely help me and maybe some readers to remember the facts in the books more easily.

I apologize if these repetitions are irritating to some readers.

Chapter 1

Inflamed Heart (Myocarditis)

Love is an inflamed heart but not in this book!

What is Inflamed Heart (Myocarditis)?

Myocarditis is the inflammation of the heart muscle.

Myocarditis is acute or chronic inflammation of the myocardium - and may manifest in a similar way to myocardial infarction.

The disorder is called pediatric myocarditis when it happens in children.

Myocardial destruction may result in dilated cardiomyopathy.


The exact incidence of myocarditis is not known.

A study suggested that myocarditis is the cause of sudden cardiac death in 8.6% of cases and is identified in up to 9% of post-mortem examinations

What are the causes of Inflamed Heart (Myocarditis)?


Myocarditis is a rare disorder.

Most of the time, it is produced by an infection that reaches the heart.

When the patient has an infection, the immune system produces special cells to fight off disease.

When the infection involves the heart, the disease-fighting cells go into the heart.

The chemicals made by these cells can also injure the heart muscle.

As a consequence, the heart can become thick, swollen, and weak.

Many cases are induced by a virus that reaches the heart.


Viral infection is the most frequent cause of acute myocarditis

Coxsackievirus is the most frequent viral cause in Europe and the USA

Most viruses are potential agents, such as influenza (flu) virus, adenovirus, parvovirus B19, enteroviruses, cytomegalovirus, HIV, Epstein-Barr virus and hepatitis A and hepatitis C.

Worldwide the most frequent bacterial cause is diphtheria.

It may also be produced by bacterial infections such as Lyme disease, streptococcus, mycoplasma, and chlamydia.

There are also spirochetal, fungal, parasitic and rickettsial causes.

The protozoal Chagas' disease is a common entity worldwide

Other causes of myocarditis are:

a. Autoimmune disorders that cause inflammation throughout the body


1. Sarcoidosis.

2. Systemic lupus erythematosus.

3. Scleroderma.

4. Chlamydophila pneumoniae (chlamydial pneumonia).

5. Churg-Strauss syndrome.

6. Inflammatory bowel disease.

7. Giant cell myocarditis.

8. Type 1 diabetes mellitus.

9. Kawasaki disease.

10. Myasthenia gravis.

11. Polymyositis.

12. Thyrotoxicosis.

13. Granulomatosis with polyangiitis (Wegener's granulomatosis).

14. Heart transplant rejection.

b. Reactions to certain medicines, such as certain chemotherapy drugs

Drugs causing hypersensitivity reactions:

1. Clozapine,

2. Acetazolamide,

3. Amitriptyline,

4. Cefaclor,

5. Colchicine,

6. Furosemide,

7. Isoniazid,

8. Lidocaine,

9. Methyldopa,

10. Penicillin,

11. Phenytoin,

12. Streptomycin,

13. Tetracycline,

14. Thiazides and

15. Tetanus toxoid.

Eosinophilic myocarditis is a rare form of myocardial inflammation with variable cause.

In developed countries, the most frequent causes are hypersensitivity or allergic reactions, as well as numerous disorders leading to eosinophilia

c. Exposure to chemicals in the environment, such as heavy metals

Toxic myocarditis

Heavy metal poisoning:

1. Lead,

2. Copper,

3. Iron.

Drugs may exert a direct cytotoxic effect:

1. Ethanol,

2. Cytotoxic antibiotics (anthracyclines - e.g., doxorubicin)

3. Amphetamines,

4. Cocaine,

5. Cyclophosphamide,

6. Fluorouracil,

7. Lithium,

8. Interleukin-2 and

9. Trastuzumab.


1. Arsenic,

2. Insect stings and bites,

3. Phosphorus,

4. Carbon monoxide and

5. Inhalants.

Physical agents

1. Electric shock

2. Hyperpyrexia

3. Radiation/radiotherapy

Sometimes the exact cause may not be discovered.

What are the symptoms of Inflamed Heart (Myocarditis)?


The presentation may range from asymptomatic changes seen on ECG to fulminant heart failure, arrhythmias and sudden cardiac death:

1. Patients may be asymptomatic with ECG abnormalities.

2. Others may have severe heart failure and left ventricular dysfunction (LVD).

There may be no symptoms.

Symptoms may be similar to the influenza infection.

If symptoms occur, they may be:

1. Fatigue or listlessness (>50% of patients).

2. Chest pain that may resemble a heart attack (35% of patients).

3. Fever (20% of patients) with other signs of infection including headache, muscle aches, sore throat, diarrhea, or rashes

4. Joint pain or swelling

5. Dyspnea or Rapid breathing

6. Palpitations.

7. Rapid heart rate or Tachycardia (may occur).

8. Heart sounds - soft S1 or S4 gallop rhythm.

9. Signs of heart failure.

10. Leg swelling

11. Pale, cool hands and feet (a sign of poor circulation)

Other symptoms that may occur with this disease:

1. Fainting, often related to irregular heart rhythms

2. Low urine output

How is Inflamed Heart (Myocarditis) Diagnosed?


Myocarditis may not be easy to diagnose because the signs and symptoms often imitate those of other heart and lung diseases or a bad case of the flu.

The doctor may hear a rapid heartbeat or abnormal heart sounds while listening to the child’s chest with a stethoscope.

A physical examination may find fluid in the lungs and swelling in the legs in older children.

There may be signs of infection, such as fever and rashes.

A chest x-ray can show enlargement (swelling) of the heart or normal cardiac silhouette but pericarditis or overt medical congestive heart failure is linked with cardiomegaly.

If the doctor identifies myocarditis based on the examination and chest x-ray, an electrocardiogram may also be done to confirm the diagnosis.

ECG: changes may be ST-segment elevation/depression, T-wave inversion, atrial arrhythmias, transient atrioventricular (AV) block.

Other tests that may be required are:

1. Blood cultures to check for infection

2. Blood tests to look for antibodies against viruses or the heart muscle itself

a. ESR or CRP (elevated in 60%),

b. Creatine kinase (often elevated, as are other markers of myocardial cell damage, including troponin I and troponin T)

3. Blood tests to check liver and kidney function

4. Full blood count: leukocytosis in 25%,

5. Heart biopsy (the most accurate way to confirm the diagnosis, but not always needed)

6. Special tests to check for the presence of viruses in the blood (viral PCR)

a. Viral or Chagas' serology may be useful occasionally

b. Auto-antibodies (to screen for systemic autoimmune disease - e.g., scleroderma)

7. Endomyocardial biopsy (the gold standard test) is sometimes done - but has only limited sensitivity and specificity

8. Cardiac MRI can differentiate transient and permanent tissue damage

Cardiac MRI is medically useful to distinguish acute myocarditis from myocardial infarction

It may also detect:

a. Vascular redistribution.

b. Interstitial and alveolar edema.

c. Pleural effusion.

What is the treatment of Inflamed Heart (Myocarditis)?


Patients with signs of acute myocarditis (fever, WCC, flu-like sickness and hemodynamic compromise) should be moved to ITU, as ventricular support may become essential.

Treatment is directed at the cause of the disorder, and may require:

1. Antibiotics to fight bacterial infection

2. Medicines called steroids to reduce swelling

Corticosteroids do not reduce mortality for people diagnosed with viral myocarditis and low left ventricular ejection fraction (LVEF).

There is some evidence that corticosteroids may increase cardiac function but this evidence is only from small, low-quality studies

3. If the heart muscle is weak, the doctor will prescribe medicines to treat heart failure.

a. Diuretics to remove excess water from the body

b. Low-salt diet

c. Reduced activity

4. Abnormal heart rhythms may need the use of other medicines.

5. The patient may also require a device to correct an irregular heartbeat such as:

a. A pacemaker, or

b. Implantable cardioverter-defibrillator.

6. If a blood clot is in the heart chamber, the patient will also receive blood thinning medicine.

The usage of anticoagulation is the same as in patients with non-ischemic dilated cardiomyopathy

Anticoagulation is normally indicated for patients with concurrent atrial fibrillation or arterial or venous thromboembolism

7. Intravenous immunoglobulin (IVIG), a medicine made of substances (called antibodies) that the body produces to fight infection, to control the inflammatory process

There is presently no evidence to treat with the routine use of intravenous immunoglobulin for presumed viral myocarditis in children or adults.

Infrequently, a heart transplant may be required if the heart muscle has become very weak or the patient has other health disorders.

Patients may recover or go on to intractable heart failure (mechanical support devices may be needed, as precipitous cardiac decompensation can occur).

Treatment of acute myocarditis is still mainly supportive, except for giant cell myocarditis where steroids have been shown to increase survival

In patients with serious myocarditis and symptomatic hypotension, the use of intravenous inotropes, such as phosphodiesterase inhibitors (e.g., milrinone) or adrenergic agonists (e.g., dobutamine or dopamine) may be needed

After recovery from acute myocarditis, patients should be advised to limit activity for several months

What is the prognosis of Inflamed Heart (Myocarditis)?


The outcome for patients with acute myocarditis is very good dependent on medical manifestation, LVEF (Left ventricular ejection fraction) and pulmonary artery pressure

The outcome can vary, depending on the cause of the problem and a person’s overall health.

Some people may recover completely.

Others may have lasting heart failure.

What are the complications of Inflamed Heart (Myocarditis)?


1. Dilated cardiomyopathy

2. Congestive cardiac failure

3. Pericarditis

4. Pulmonary edema

5. Cardiogenic shock

6. Dysrhythmias

7. Recurrent myositis

How is Inflamed Heart (Myocarditis) prevented?


The doctor should treat conditions that cause myocarditis promptly to reduce the risk.

Chapter 2


Myocarditis is an inflammatory disorder of the myocardium with a wide range of medical manifestations, from subtle to destructive.

More specifically, it is considered as an inflammatory infiltration of the myocardium with damage and degeneration of adjacent myocytes.

Myocarditis normally presents in an otherwise healthy looking person and can lead to rapidly progressive (and often fatal) heart failure and arrhythmia.

In the medical setting, myocarditis is the same as with inflammatory cardiomyopathy.

It is diagnosed by established histological, immunological, and immunochemical guidelines.

Myocarditis is further classified as:

1. Fulminant myocarditis

This accompanies a viral prodrome

The distinct start of illness consists of serious cardiovascular compromise with poor ventricular function and multiple areas of active myocarditis.

It either recovers spontaneously or leads to death

2. Acute myocarditis

Less distinct onset of illness, with established ventricular dysfunction; may progress to dilated cardiomyopathy

3. Chronic active myocarditis

Less distinct onset of illness, with clinical and histological relapses;

The development of ventricular dysfunction is linked with chronic inflammatory changes (such as giant cells)

4. Chronic persistent myocarditis

Less distinct onset of illness;

There is a persistent histological infiltrate with foci of myocyte necrosis but without ventricular dysfunction (despite symptoms such as chest pain, palpitations)

The medical presentation and progression of myocarditis appears like this, especially in the absence of ongoing histological evaluation.


Myocarditis is probably caused by:

1. A wide range of infectious organisms,

2. Autoimmune disorders, and

3. Exogenous agents, with genetic and environmental predisposition.

Most cases are presumed to be caused by a frequent pathway of host-mediated, autoimmune-mediated injury, even though direct cytotoxic effects of the causative agent and injuries due to cytokine expression in the myocardium may play some part in myocarditis cause.

Injury happens through these mechanisms:

1. Direct cytotoxic effect of the causative agent

2. Secondary immune response, which can be activated by the causative agent

3. Cytokine expression in the myocardium (e.g., tumor necrosis factor̶ alpha, nitric oxide synthase)

4. Aberrant induction of apoptosis

Myocardial damage has 2 main phases:

1. Acute phase (first 2 wk)

Myocyte damage is a direct after effect of the causative agent, which induces cell-mediated cytotoxicity and cytokine release, adding to myocardial injury and dysfunction.

The detection of the causal agent is not frequent during this phase

2. Chronic phase (>2 wk)

The persistent myocyte damage is autoimmune in nature, with linked abnormal expression of human leukocyte antigen (HLA) in myocytes (and in the case of viral myocarditis, presence of the viral genome in myocardium)

Viral myocarditis

In viral myocarditis, viral isolates differ in tissue virulence and tropism.

Coxsackie virus A9 is a self-limiting myocarditis

Coxsackie virus B3 produces severe myocarditis leading to a high mortality rate.

The induction of the coxsackie-adenovirus receptor (CAR) and the complement deflecting protein, decay accelerating factor (CD55, DAF) may permit efficient internationalization of the viral genome.

Viral replication may cause further disturbance of metabolism and to interference of inflammation and its reaction.

Vasospasm induced by endothelial cell viral infection may also add to more injury

New evidence of dystrophin disturbance by expression of enteroviral protease 2A points to another unique pathogenic mechanism.

On the contrary, some viruses (e.g., parvovirus B19) may have adverse effects on pericapillary depositions, adding to poor diastolic function rather than to direct myocyte damage.

Regardless, viral persistence supplies the essential stimuli for autoimmune or other inflammatory reactions.

Idiopathic myocarditis

About 50% of the time, myocarditis is categorized as idiopathic

A report found that 82% of the pediatric cases studied were regarded idiopathic.

The doctors also found that 3% of cases in the study had a known bacterial or viral cause, and that 6% of cases were linked to other diseases.

In idiopathic patients, it is often believed to be a viral cause but not proven, even with new modern immunohistochemical and genomic studies.

Studies on patients with idiopathic dilated cardiomyopathy found presence of viral particles in endomyocardial biopsy samples in up to two thirds of the patients.

Causes of myocarditis are:

A. Infections:


1. Enterovirus,

2. Coxsackie B,

3. Adenovirus,

4. Influenza,

5. Cytomegalovirus,

6. Poliomyelitis,

7. Epstein-Barr virus,

8. HIV-1,

9. Viral hepatitis,

10. Mumps,

11. Rubeola,

12. Varicella,

13. Variola/vaccinia,

14. Arbovirus,

15. Respiratory syncytial virus,

16. Herpes simplex virus,

17. Yellow fever virus,

18. Rabies,

19. Parvovirus


1. Scrub typhus,

2. Rocky Mountain spotted fever,

3. Q fever


1. Diphtheria,

2. Tuberculosis,

3. Streptococci,

4. Meningococci,

5. Brucellosis,

6. Clostridia,

7. Staphylococci,

8. Melioidosis,

9. Mycoplasma pneumoniae,

10. Psittacosis


1. Syphilis,

2. Leptospirosis/Weil disease,

3. Relapsing fever/Borrelia, Lyme disease


1. Candidiasis,

2. Aspergillosis,

3. Cryptococcosis,

4. Histoplasmosis,

5. Actinomycosis,

6. Blastomycosis,

7. Coccidioidomycosis,

8. Mucormycosis

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