Myocarditis

Myocarditis

1. Definition
   Myocarditis is an inflammation of the heart muscle (myocardium) that may impair the contractile function of the heart. It is an uncommon but potentially serious condition that often requires early recognition.

2. Synonyms
   Myocardial inflammation – another term used to describe the same disease process.

3. Causes / Etiology

1. Viral infection – most common cause; coxsackie B, adenovirus, parvovirus B19 and influenza may directly injure myocardial cells.
2. Bacterial infection – organisms such as Staphylococcus, Streptococcus and Mycobacterium tuberculosis can produce myocarditis, especially in the setting of sepsis or endocarditis.
3. Parasitic infection – Trypanosoma cruzi (Chagas disease) and Toxoplasma gondii are important in endemic areas and in immunocompromised hosts.
4. Fungal infection – Aspergillus and Candida species may involve the myocardium in patients with severe immunosuppression.
5. Drug‑induced – hypersensitivity to antibiotics, antiepileptics, or chemotherapeutic agents can trigger an immune‑mediated myocardial inflammation.
6. Autoimmune / systemic disease – systemic lupus erythematosus, rheumatoid arthritis and sarcoidosis may produce a secondary myocarditis.

4. Types / Classification

Acute myocarditis
Definition – sudden onset inflammation lasting days to weeks.
Causes – predominantly viral, also bacterial toxins or drug hypersensitivity.
Clinical features – chest discomfort, dyspnoea, palpitations, low‑grade fever and sometimes syncope.
Duration – usually resolves within 2–4 weeks if uncomplicated.
Differences – marked elevation of cardiac enzymes and prominent ECG changes are more common than in chronic form.

Chronic myocarditis
Definition – persistent inflammation extending for months or years.
Causes – ongoing viral persistence, autoimmune mechanisms or genetic predisposition.
Clinical features – progressive fatigue, exertional dyspnoea, peripheral oedema and occasional arrhythmias.
Duration – may last indefinitely and lead to remodeling of the ventricle.
Differences – less dramatic enzyme rise, but gradual decline in left‑ventricular function is characteristic.

5. Pathophysiology / Pathology

Step 1 – Entry of pathogen or drug antigen into myocardial tissue.
Step 2 – Activation of innate immune cells (macrophages, neutrophils) and release of cytokines such as interleukin‑1 and tumour‑necrosis factor.
Step 3 – Recruitment of adaptive immune response; T‑lymphocytes attack infected myocytes, causing cell necrosis.
Step 4 – Healing phase with fibroblast proliferation leading to interstitial fibrosis and possible scar formation.
Step 5 – Fibrotic replacement impairs contractility and may predispose to arrhythmias.

6. Clinical Features

General – fatigue, shortness of breath on exertion, low‑grade fever and malaise.
Acute specific – sharp chest pain that may mimic myocardial infarction, palpitations, rapid heart rate and occasional syncope.
Chronic specific – gradual dyspnoea, ankle swelling, reduced exercise tolerance and occasional ventricular ectopy.
Relevance – early recognition of chest pain and arrhythmia helps differentiate from coronary artery disease.

7. Complications

Acute complications – acute heart failure, life‑threatening ventricular arrhythmias and cardiogenic shock.
Chronic complications – dilated cardiomyopathy, chronic heart failure and increased risk of sudden cardiac death.
Importance – timely treatment can prevent progression to irreversible ventricular dilation.

8. Investigations / Diagnosis

Routine tests – ECG (ST‑segment changes, arrhythmias), complete blood count and inflammatory markers (ESR, CRP).
Specific tests – serum cardiac troponin (indicates myocardial injury), echocardiography (assesses ventricular function and wall motion) and cardiac MRI (detects myocardial oedema and late gadolinium enhancement).
Confirmatory test – endomyocardial biopsy (histological proof of inflammatory infiltrates and necrosis).
Purpose – each test adds information about the extent of injury, functional impact and guides therapy.

9. Differential Diagnosis

1. Acute coronary syndrome – distinguished by coronary artery occlusion on angiography and typical plaque‑related ECG changes.
2. Pulmonary embolism – presents with sudden dyspnoea and pleuritic chest pain; CT pulmonary angiography confirms diagnosis.
3. Pericarditis – characterised by pericardial friction rub and diffuse ST‑elevation without reciprocal changes.

10. Management / Treatment

General management – bed rest, avoidance of strenuous activity, close monitoring of heart rate and blood pressure, and regular follow‑up echocardiograms.
Modern medicine treatment – non‑steroidal anti‑inflammatory drugs for mild cases, corticosteroids or other immunosuppressants for autoimmune or severe viral forms, antiviral agents when a specific virus is identified, and standard heart‑failure therapy (ACE inhibitors, beta‑blockers, diuretics) if ventricular dysfunction is present.
Diet and lifestyle advice – low‑salt diet to reduce fluid retention, moderate fluid restriction if congestive symptoms develop, regular gentle aerobic exercise once stable, and avoidance of alcohol and tobacco to lessen myocardial stress.

11. Homeopathic Therapeutics

Aconitum napellus

1. Causation – sudden onset after exposure to cold wind or fright.
2. Characteristic symptoms – intense anxiety, fear of death, rapid pulse.
3. Modalities – symptoms worse from heat, better in cool fresh air.
4. Mental state – restlessness, feeling of impending doom.
5. Thirst and appetite – great thirst for cold water, appetite poor.
6. Discharges – dry tongue, scanty urine.
7. Physical generals – flushed face, dilated pupils.
8. Suitable constitution – young, active individuals who become suddenly ill after shock.
9. How it helps – addresses the acute panic‑driven inflammation and supports rapid recovery of myocardial function.

Apis mellifica

1. Causation – insect sting or allergic reaction leading to swelling.
2. Characteristic symptoms – burning pain relieved by cold applications, swelling of the chest wall.
3. Modalities – worse from warmth, better from cold compresses.
4. Mental state – irritability, desire to be left alone.
5. Thirst and appetite – thirst for cold drinks, appetite diminished.
6. Discharges – watery, thin secretions from the nose and throat.
7. Physical generals – red, hot skin with edema.
8. Suitable constitution – patients with a history of hypersensitivity and marked swelling.
9. How it helps – reduces inflammatory oedema and eases chest discomfort.

Arsenicum album

1. Causation – exposure to toxic substances or prolonged exhaustion.
2. Characteristic symptoms – burning chest pain, restlessness, weakness.
3. Modalities – worse from warm drinks, better from cool fresh air.
4. Mental state – anxiety about health, fear of contamination.
5. Thirst and appetite – great thirst for cold water, appetite poor.
6. Discharges – scanty, dry stools.
7. Physical generals – trembling, cold extremities.
8. Suitable constitution – thin, anxious individuals who become ill after over‑work.
9. How it helps – modulates the toxic‑induced immune response and stabilises cardiac rhythm.

Belladonna

1. Causation – sudden high‑grade inflammation, often after a febrile illness.
2. Characteristic symptoms – throbbing chest pain, rapid pulse, fever.
3. Modalities – worse from heat, better in cool, dark rooms.
4. Mental state – delirium, confusion, desire to be alone.
5. Thirst and appetite – thirst for cold water, appetite reduced.
6. Discharges – dry mouth, scanty urine.
7. Physical generals – flushed face, dilated pupils, hot skin.
8. Suitable constitution – patients with a sudden, violent onset of symptoms.
9. How it helps – controls the hyper‑acute inflammatory surge and eases pain.

Bryonia alba

1. Causation – physical trauma or over‑exertion of the heart.
2. Characteristic symptoms – sharp, stitching chest pain worsened by movement.
3. Modalities – worse from motion, better when at rest.
4. Mental state – irritable, wants to be left alone.
5. Thirst and appetite – great thirst for large quantities of water, appetite poor.
6. Discharges – dry cough, scanty sputum.
7. Physical generals – dry skin, constipation.
8. Suitable constitution – individuals who aggravate symptoms by any activity.
9. How it helps – relieves pain that is aggravated by motion and promotes rest.

Digitalis purpurea

1. Causation – pre‑existing heart disease with reduced output.
2. Characteristic symptoms – feeling of heaviness in the chest, visual disturbances (yellow‑green halos).
3. Modalities – worse from exertion, better with rest.
4. Mental state – confusion, forgetfulness.
5. Thirst and appetite – thirst for cold water, appetite diminished.
6. Discharges – greenish‑yellow urine, dry tongue.
7. Physical generals – bradycardia, weak peripheral pulse.
8. Suitable constitution – older patients with chronic heart failure.
9. How it helps – supports weakened myocardium and improves contractility when used in low dose.

Kali mur

1. Causation – inflammatory conditions of the heart following infection.
2. Characteristic symptoms – deep, boring chest pain radiating to the back, feeling of heaviness.
3. Modalities – worse from cold, better from warmth.
4. Mental state – melancholy, desire for solitude.
5. Thirst and appetite – thirst for warm drinks, appetite poor.
6. Discharges – thick, yellow sputum if pulmonary congestion present.
7. Physical generals – swollen ankles, low‑grade fever.
8. Suitable constitution – patients with a history of recurrent infections and chronic inflammation.
9. How it helps – diminishes chronic inflammatory processes and reduces oedema.

Lycopodium clavatum

1. Causation – digestive disturbances leading to low‑grade inflammation of the heart.
2. Characteristic symptoms – bloating, flatulence, and a sense of heaviness in the chest after meals.
3. Modalities – worse in the evening, better after light exercise.
4. Mental state – self‑critical, fear of failure.
5. Thirst and appetite – thirst for warm drinks, appetite for sweets.
6. Discharges – sticky, yellow mucus from the throat.
7. Physical generals – liver enlargement, constipation.
8. Suitable constitution – individuals with a timid nature and digestive upset.
9. How it helps – balances the digestive‑related aggravation of myocardial inflammation.

12. Prognosis
    The outcome ranges from complete recovery within weeks in mild viral cases to progression to dilated cardiomyopathy and chronic heart failure in severe or untreated disease. Early diagnosis and appropriate therapy improve survival; delayed treatment increases the risk of permanent ventricular dysfunction.

13. Prevention
    Avoidance of known viral infections (hand hygiene, vaccination where available), judicious use of potentially cardiotoxic drugs, and control of systemic autoimmune disorders are essential preventive measures. These steps markedly reduce the incidence of new myocardial inflammation.

14. Diet

Recommended foods – fresh fruits, leafy vegetables and whole‑grain cereals; they provide antioxidants and fibre that support cardiac health.
Avoided foods – processed meats, fried foods and sugary beverages; they promote inflammation, lipid accumulation and can worsen myocardial injury.