Transcript file ( Acute Myocarditis: Patient Case)

Nick Wytiaz
University of Pittsburgh
PharmD Candidate, 2012
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CC: shortness of breath
HPI: 18 yo WM presented to outside ED with
SOB, DOE. Also c/o chest pain 5 days prior.
 EKG: atrial fibrillation, rapid ventricular rate (150s)
 CT: cardiomegaly
 ECHO: severe LV dysfunction, EF 5-10%
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Transferred to AGH CCU
PMH: not significant
 SH: Denies tobacco, drugs
Occasional EtOH
 FH: Uncle died age 53 of AMI
 Allergies: Amoxicillin (rash)
 Home Meds: None
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Physical Exam:
 T 98.6oF, BP 85/54, HR 120-130s (AF), RR 16
 Ht 75”, Wt 81.3kg
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Pertinent Negative Labs:
 Cardiac enzymes, Lyme titer, CVA panel, ESR,
 Thyroid function panel, CRP, ESR
 Normal electrolytes, coags, renal function
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Pertinent Positive Labs:
 WBC 12.5
Tests
 ECHO
 Severe LV dysfunction
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Cardiac MRI
 EF 14%
 Biventricular involvement
 No valvular dysfunction
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Right Heart Cath
 Lymphocyte infiltration
 Normal hemodynamics
Acute Lymphocytic
Myocarditis
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Definition
 Inflammatory disease of the myocardium
 AKA “inflammatory cardiomyopathy”
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Epidemiology
 1-10 cases per 100,000 persons
 Major cause of sudden, unexpected death (~20%
of cases) in adults < 40 years old
 Myocardial inflammation found in 1 -9% of
routine postmortem examinations
Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000;343(19):1388–98
Drory Y, Turetz Y, Hiss Y, et al. Sudden unexpected death in persons less than 40 years of age. Am J Cardiol . 1991;68:1388-1392
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Lieberman Classification
 Fulminant myocarditis
▪ Viral, severe CV compromise, multiple foci
 Acute myocarditis
▪ Less distinct onset, established ventricular dysfunction
 Chronic active myocarditis
▪ Less distinct onset, development of ventricular dysfunction
associated with chronic inflammatory changes
 Chronic persistent myocarditis
▪ Less distinct onset; persistent histologic infiltrate with foci of
myocyte necrosis but without ventricular dysfunction
Lieberman EB, Hutchins GM, Herskowitz A, et al. Clinicopathologic description of myocarditis. J Am Coll Cardiol. 1991; 18: 1617–1626
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Dallas Criteria
 Active myocarditis
▪ inflammatory cellular infiltrate with myocyte necrosis
 Borderline myocarditis
▪ inflammatory cellular infiltrate without myocyte injury
 Further characterization based on infiltrate type,
amount, and distribution
Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol. 1987;1:3-14.
VIRAL / INFECTIOUS
 Coxsackie B virus
 Adenovirus
 Enterovirus
 Hepatitis C
 CMV
 Influenza
 EBV
 Parvovirus B19
 HIV-1
 Bacterial, Fungal, Parasitic
NON-INFECTIOUS
 Cardiotoxins
 Catecholamines
 Chemotherapeutics
 Cocaine
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Hypersensitivity Rxn
 Sulfonamides
 Insect Bite
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Systemic Diseases
 Giant cell myocarditis
 Kawasaki
~50% of cases “idiopathic”
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3 Supposed Phases
1. Direct myocardial invasion by virus / other
infectious agents
2. Autoimmune response : CD4+ activation, B cell
expansion
3. Myocytolysis, local inflammation, “anti-heart”
auto-antibodies
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Could progress to Dilated Cardiomyopathy
Magnani JW, Dec GW. Contemporary reviews in cardiovascular medicine: myocarditis. Circulation. 2006; 113: 876-890
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Diagnosis
 Difficult due to non-specific symptoms
 Based on medical history and physical exam
 Elevated pancreatic enzymes
▪ Serum amylase, lipase 3x ULN
 Confirm with imaging test
▪ Ultrasound, CT, or MRI
6 Balthazar
EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-6.
TREAT UNDERLYING CAUSE!
MILD PANCREATITIS
 Self-limiting, most common
 Supportive care
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Fluid resuscitation
Oxygen
Analgesia
Antiemetics
NPO until pain relief
MODERATE – SEVERE PANCREATITIS
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 IV carbapenem x 14 days
Monitoring
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Vitals
Hemodynamics
Signs of infection
Organ system failure
7 Banks PA, Freeman ML. Practice
Organ failure, complications
Ranson criteria, CT severity
index to categorize
ICU Support & Monitoring
Antibiotics
 Prophylaxis not recommended
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Nutritional Support
 After hemodynamics stabilize
 NJ vs. NG vs. TPN
Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatits. Gastroenterology. 2007;132:2022.
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Acute fluid collections / Pseudocyst
Intra-abdominal infections
 Within 1-3 weeks
 Fluid collections or necrotic pancreas
 Intestinal florae predominant source
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Infected vs. sterile pancreatic necrosis
 Sterile: 25% mortality
▪ aggressive medical management
 Infected: 60% mortality
▪ surgical debridement or percutaneous drain
8 Heinrich
S, Schafer M, Rousson V, et al. Evidenced-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006;243:154-68.
1.
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Moderate-severe acute pancreatitis
D5NS 200mL/hr
NPO except meds
Hydromorphone 0.5mg IVP Q6H for pain
Ondasetron 4mg IVP Q6H for nausea
Calcium level, lipid panel
Blood culture, CBC
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Leukocytosis
 WBC 26, unknown origin, no micro results
 Imipenem-cilastatin 500mg IV Q8H
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Severe Abdominal Pain
 “More than 10” on pain scale
 Increases hydromorphone to Q4H
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Nutrition Support
 Clear liquids ordered
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3 days post-ICU admission
 Hemodynamically stable
 Denies abdominal pain
 Lipase from 1159 to 240
 WBC from 26 to 18
 Started on clear liquid diet
 Contrast CT for possible necrosis or infection
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Transferred to the floor
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Inflammatory condition of pancreas
 Abdominal pain, elevated pancreatic enzymes
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Identify and correct underlying cause
 Gallstones
 Alcohol
 Indeterminate
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Categorize by severity
 Mild: supportive care, monitoring, NPO
 Mod-Severe: ICU monitoring / support, nutrition
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Necrosis increases morbidly & mortality
 Sterile: ICU management
 Infx: carbapenem IV x14d, surgical debridement
1
Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008:371:143-52.
2 Swaroop VS, Chari ST, Clain JE. Severe acute pancreatitis. JAMA. 2004;291:2865-8.
3 Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics, 2004.
Gastroenterology. 2004;126:1448–53.
4 Badalov N, Baradarian R, Kadirawel I, et al. Drug-induced acute pancreatitis: an
evidence-based review. Clin Gastrienterol Hepatol 2007;5:648.
5 National Digestive Diseases Information Clearinghouse. Pancreatitis. NIH
Publication No. 08–1596. July 2008. Available at www.digestive.niddk.nih.gov.
6 Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT
in establishing prognosis. Radiology. 1990;174(2):331-6.
7 Banks PA, Freeman ML. Practice Parameters Committee of the American College of
Gastroenterology. Practice guidelines in acute pancreatits. Gastroenterology.
2007;132:2022.
8 Heinrich S, Schafer M, Rousson V, et al. Evidenced-based treatment of acute
pancreatitis: a look at established paradigms. Ann Surg. 2006;243:154-68.