Myocarditis

MYOCARDITIS

 
1. Oorzaken
    
      Niet-infectieus

- toxisch:

    - medicatie:

        -  overgevoeligheid aan penicilline, sulfamethoxazole (Bactrim, Eusaprim) of sulfadiazine (Flammazine)

        - chemotherapie

        - koolwaterstoffen

    - intoxicatie

        - koolmonoxide

        - zware metalen

        - arseen

- zwangerschap: postpartum cardiomyopathie
- auto-immuunziekten: SLE, ziekte van Kawasaki, Wegener granulomatose
- sarcoidose
- transplantrejectie
- bestraling
 

      Infectieus

- parasitair:

    - Protozoa

        - ziekte van Chagas: wereldwijd grootste oorzaak van myocarditis. Enkel in Centraal en Zuid-Amerika.  Ongeveer 20 miljoen personen zijn geinfecteerd door Tryposama Cruzi.

        - Toxoplasmose

        - Trypanosomias

        - Malaria

        - Leishmaniasis

    - Spirocheten (Syfilis)

    - Rickettsia

    - Wormen (Helminthic)

        - Trichinose

        - Echinococcus

        - Schistosomias

        - Cysticercosis

- Schimmelinfectie

    - candidiasis

    - aspergillosis

    - cryptococcus

    - histoplasmosis

    - actinomycosis

- bijtwonden

    - schorpioen

    - slang

    - zwarte weduwe

- bacterieel

    - difterie

    - tuberculose

    - brucellose

    - psittacosis

    - meningococcen

    - mycoplasma

    - groep A streptococcen

- Viraal

    - enterovirus (coxsackie B)

    - adenovirus

    - herpesvirus

    - CMV

    - Hepatitis C

    - Influenza

    - Mazelen

    - Rubeola

    - Variola

    - Gele koorts

    - Rabies

    - HIV

 

 

2. Diagnostiek
- anamnese:

    - recent ontstane vermoeidheid

    - gedaalde inspanningstolerantie

    - dyspnee

    - thoracale last bij AH

    - koorts

    - hartkloppingen

- lichamelijk onderzoek:

    - matige vorm: vitale parameters: zwakke pulsaties (hypotensie, tachycardie), cyanose, opgezette venae jugularis.  Bij auscultatie S1 bedekt/zwak en zelden een diastolisch geruis.

    - fulminante vorm: reutels, opzetting halsvenen, perifeer oedeem, hepatomegalie

- ECG:

    - ST- en T-afwijkingen maar nonspecifiek en transient.

    -  ritmestoornissen.

    - Geleidingsstoornissen

- Rx Thorax: deze varieert van normaal tot cardiomegalie en longoedeem
- Labo:

    - CBC

    - CRP

    - Hartenzymen

    - infectie: virale titers, titers voor mycoplasma, antistreptolysine, hepatitistesten, monospot, CMV, bloedculturen

- Echocardio:

    - linker ventrikeldillatatie, hypertrofie.  Thrombus?

    - Rechter ventrikel: slechte functie is een slechte prognose.

    - vullingstoestand van de ventrikels.

- scintigrafie: antimyosine antilichamen, gallium 67 gelabeld of Indium 111 gelabeld.
- MRI met gadolinium: cardiale inflammatie of necrose
- biopsie rechter ventrikel

 

 
3. Therapie
    
      Eerste opvang
- eventueel longoedeem behandelen
- ritmestoornissen behandelen: behandeling van tachycardie, bradycardie.  Zo nodig transveneuze pacing.  Cave: geef GEEN NSAID in de acute fase!
 
      Spoeddienst
- cardiale therapie:

    - preload en afterload verminderen.  ACE-inhibitoren verminderen de inflammatie en de afterload.  Ook diuretica passen hierin

    - bloedverdunners bij thrombus of verminderde LV functie

    - ritmestoornissen behandelen.  Digoxine bij atriumfibrillatie

- specifieke therapie

    - CMV: hyperimmunoglobuline therapie.  Bij kinderen worden bij virale myocarditis IV immunoglobulines gegeven.

    - Immunosuppressieve therapie: het effect is niet bewezen

- effecten op termijn:

    - mortaliteit op 5 jaar = 56%.

    - Harttransplantatie kan een oplossing bieden.

    - 20 à 33% geneest volledig.

 

 

Eerste opvang
- eventueel longoedeem behandelen
- ritmestoornissen behandelen: behandeling van tachycardie, bradycardie.  Zo nodig transveneuze pacing.  Cave: geef GEEN NSAID in de acute fase!

 

 

Spoeddienst
- cardiale therapie:

    - preload en afterload verminderen.  ACE-inhibitoren verminderen de inflammatie en de afterload.  Ook diuretica passen hierin

    - bloedverdunners bij thrombus of verminderde LV functie

    - ritmestoornissen behandelen.  Digoxine bij atriumfibrillatie

- specifieke therapie

    - CMV: hyperimmunoglobuline therapie.  Bij kinderen worden bij virale myocarditis IV immunoglobulines gegeven.

    - Immunosuppressieve therapie: het effect is niet bewezen

- effecten op termijn:

    - mortaliteit op 5 jaar = 56%.

    - Harttransplantatie kan een oplossing bieden.

- 20 à 33% geneest volledig.

 

 

REFERENTIES:

 

 

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