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Four Faces Ofacute Myopericarditis Br Heart J: first published as 10.1136/hrt.35.4.433 on 1 April 1973. Downloaded from British HeartJournal, I973, 35, 433-442. Four faces of acute myopericarditis Austen J. S. Gardiner and David Short From the Aberdeen Royal Infirmary, Aberdeen, Scotland Sixty patients with acute myocarditis or pericarditis or a combination of the two lesions, without endocarditis, were encountered by the authors in hospital and domiciliary consulting practice over a period of seven years. Similar cases have been reported under a variety of names; e.g. Coxsackie myopericarditis, acute nonspecific pericarditis, Bornholm disease, isolated myocarditis, Fiedler's myocarditis, and cardiomyopathy of pregnancy. The clinical presentation fell into 4 groups. I: I9 patients presented with classical symptoms of acute pericarditis. II: 24 presented as coronary mimics, with severe substernal pain unaffected, or only slightly affected, by respiration, posture, or movement. III: 3 presented with progressive heart failure. IV: I4 pre- sented with miscellaneous symptoms, most frequently resembling influenza. Evidence of concurrent viral illness was found in IS patients, 9 being Coxsackie infections. Other specific diseases were identified in 3 patients; but in 42, including 3 who died and were examined at necropsy, the nature of the disease could not be established. Three patients died of heart failure, and in IO others the electrocardiogram remained abnormal over 3 months after the onset; the remaining patients made a complete recovery. Nine patients relapsed, 7 of them being in the group presenting with acute pericarditis. No specific treatment was found to be of value. The term myopericarditis has been used (Smith, Acute myopericarditis is important on account of http://heart.bmj.com/ I966; British Medical Journal, 197I) to cover a its global frequency, and the difficulty it often pre- group of cases with pericarditis or myocarditis or sents in diagnosis. Most physicians encounter one both, without any evidence of endocarditis. The or two cases of acute pericarditis each year - cardi- grouping of myocarditis and pericarditis together is ologists and specialists in respiratory medicine see of value clinically in that both layers of the heart more - though these are often mistaken initially for tend to be involved in the same types of acute myocardial infarction. At the Mayo Clinic, 269 cases disease process, and particularly in the common of acute nonspecific pericarditis were diagnosed over Coxsackie virus infections. a period of io years (Connolly and Burchell, I96I). on September 25, 2021 by guest. Protected copyright. There is at the present time great confusion sur- Acute myocarditis is probably commoner than acute rounding this group of cases. Much of this arises pericarditis, but more often overlooked; it is fre- from the number of possible agents which may quently found at necropsy when it has been missed damage the myocardium and pericardium, and the during life. Gore and Saphir (I947) were able to re- fact that it is often impossible to establish the cord over IooO cases from postmortem material sub- aetiology during life, and even at necropsy. This mitted to the United States Army Institute of confusion is reflected in the nomenclature. For Pathology during the 1939-46 War. A considerable example, patients with Coxsackie B myopericarditis proportion of these cases was due to specific infec- have been reported as acute nonspecific pericarditis tions such as typhus and diphtheria, which are not or benign idiopathic pericarditis when symptoms commonly seen in civilian life; nevertheless, there of pericarditis have predominated; or as isolated were 43 in association with virus pneumonia, and 30 myocarditis, idiopathic myocarditis, or Fiedler's diagnosed as 'idiopathic'. myocarditis when myocardial damage has pre- In this paper we attempt to resolve the current dominated; or as pregnancy cardiomyopathy when confusion on the basis of our experience of the heart failure has developed during pregnancy. problem as it presents in hospital and domiciliary consulting practice among adults in the North-East of Scotland, an area with a population of approxi- Received ii September 1972. mately 500,000. Br Heart J: first published as 10.1136/hrt.35.4.433 on 1 April 1973. Downloaded from 434 Gardiner and Short Subjects and methods cultures of secondary monkey kidney, human embryonic kidney, and HeLa cells. Sera were tested for the presence We became interested in the problem of acute myo- of antibodies to Coxsackie Bi-6 viruses by means of the pericarditis in I964 after seeing a series of patients in neutralization test in HeLa cells. Complement-fixation whom the family doctor had suspected a coronary tests were carried out using the following antigens: attack. We decided to collect all cases of acute myocar- influenza A, influenza B, parainfluenza, adenovirus, ditis and acute pericarditis without evidence of endo- respiratory syncytial, psittacosis, Q fever, and Myco- carditis coming under our observation from this time, plasma pneumoniae. Criteria for recent infection were closing the series at the end of October I97I. either a fourfold rise in antibody titre or a 'high' titre; a must have been To qualify for inclusion, patient 256 or greater in the case of the Coxsackie B and influ- one us evi- examined by of personally and have shown enza viruses, 128 or greater in the others. For para- dence of acute cardiac involvement, either by the influenza and adenovirus a 'high' titre was not con- development of a pericardial rub or serial electrocardio- sidered sufficient without epidemiological evidence or graphic abnormalities. It was also essential that acute myocardial infarction could be reasonably excluded. At virus isolation. Virological tests were not undertaken in io patients, first we were inclined to omit any patient who gave a either because a non-viral cause such as systemic lupus or but this history of effort angina previous infarction, erythematosus or rheumatic fever was obvious, or because might have given the impression that acute myoperi- the patient was afebrile and an infection was not carditis did not occur in patients with coronary heart the disease. We therefore decided to accept patients with suspected at time. acute pericarditis provided the pain was different in site and quality from any previous coronary pain, and pro- Clinical spectrum vided there was no electrocardiographic or enzymic Four distinct clinical presentations were encoun- evidence suggestive of recent infarction. There is good in of and though some evidence that acute infarction is only complicated by tered this group 6o patients, pericarditis if the infarct is large (Thadani et al., I97I); patients had features of more than one group, it was so this simplifies the problem of differential diagnosis. possible to assign each case to one of the four groups During the seven-year period from November I964 by reference to the presenting symptom (Fig. 2). to October I97I we saw 6o patients who fulfilled the criteria laid down above. Forty-eight were admitted I: Classical acute pericarditis: I9 patients presented directly to hospital as emergencies and the remaining I2 with praecordial pain which was strikingly affected were seen initially in their home or in urgent outpatient by respiration or posture (sometimes by both fac- consultation. The age and sex of the patients are shown in tors), and who were found to have a pericardial rub, http://heart.bmj.com/ Fig. i. Since our work was practically confined to adults the youngest patient in the series was aged 13 years. a classical electrocardiographic pattern of pericardi- In an attempt to establish the aetiology, the following tis, or both features. screening tests were performed: the antistreptolysin 0 titre, Brucella abortus agglutinins, immunopathology, II: Coronary mimic: 24 patients presented with and the Paul Bunnell test; in many patients the toxo- praecordial pain strongly suggestive of myocardial plasma dye test was also carried out. Virus isolation was infarction. In these patients, the pain was unaffected, attempted by innoculating throat swabs and stools into or only slightly affected, by respiration or posture, on September 25, 2021 by guest. Protected copyright. and the electrocardiogram showed abnormalities 20 consistent with early myocardial infarction. L0 Male III: Progressive heart failure: 3 patients presented ~~~~~~Female1. with heart failure which pursued a relentless course to a fatal termination. IV: Febrile and miscellaneous: 14 patients presented I 10 with miscellaneous symptoms, most commonly an E influenza-like illness, characterized by fever, sweat- ing, pains in muscles or joints, and headache. None z5 presented with praecordial pain suggestive of peri- carditis or coronary disease, and none developed heart failure. 0 As indicated above, the groups overlap to some extent. Each group contains patients with objective Age evidence of pericarditis; a number of patients in FIG. i Age and sex distribution of 6o patients with Group I had febrile symptoms and one developed acute myopericarditis. transient heart failure; several patients in Group II Br Heart J: first published as 10.1136/hrt.35.4.433 on 1 April 1973. Downloaded from Four faces of acute myopericarditis 435 I II III IV Pericord itis Coronary mimic Halurte Miscellaneous SYMPTOMS 19 pts - 24 pts 3 pts r- 14 pts s Proecordial pain_fconstantpericardial= Muscle ache (or joint pain) ---- 1,-! Headache ------'------------- Pleuritic pcin----------------
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