Oxford Medical Case Reports, 2018;1, 15–17 doi: 10.1093/omcr/omx096 Editorial EDITORIAL Iatrogenic myocarditis—biomarkers, cardiovascular MRI and the need for early diagnosis 1 1 1,2, Amrit S. Lota , Brian P. Halliday and Vassilios S Vassiliou * National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK, and Norwich Medical School, University of East Anglia Norfolk, Norfolk and Norwich University Hospital, Norwich, UK *Correspondence address. National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Tel: +020-73-52-8121, Ext. 2920; Fax: +020-73-51-8146; E-mail: firstname.lastname@example.org Myocarditis remains a challenging diagnosis that arises from a At present, the gold standard for diagnosis of myocarditis range of potential insults that can result in cardiac inﬂamma- remains an endomyocardial biopsy . Histopathological ana- tion, immune activation and functional impairment . Acute lysis with immunostaining conﬁrms the presence and charac- viral infection represents the leading aetiology followed by drug- terizes the nature of acute inﬂammatory inﬁltrates. However, induced hypersensitivity, giant cell myocarditis and cardiac the limitations of endomyocardial biopsy are many and include involvement in systemic autoimmune disease . Due to hetero- high rates of sampling error, interobserver variability and peri- geneity in clinical presentation and disease severity, accurate procedural risks of cardiac tamponade and death. For these epidemiological assessment is limited but overall prevalence is reasons, endomyocardial biopsy is rarely a practical ﬁrst step in estimated at 22 cases per 100 000 patients annually . Clozapine the diagnosis of myocarditis in the majority of centres. is the cornerstone of therapy in refractory schizophrenia and sig- Cardiovascular magnetic resonance imaging (CMR) has niﬁcantly reduces suicide rates further than other antipsychotic emerged as an important diagnostic tool for the non-invasive agents . However, cardiotoxicity resulting in myocarditis can assessment of acute myocarditis. Standard myocardial tissue occur in 1–3% of patients and can result in complications includ- characterization techniques can detect myocardial oedema, ing sudden cardiac death and heart failure [5, 6]. reactive hyperaemia and replacement ﬁbrosis from myocyte The case report by Datta and Solomon  describes a young cell death . Diagnostic accuracy is further enhanced with patient presenting acutely with chest pain, ST segment elevation novel T1 and T2 mapping approaches as shown in Fig. 1 . and mild troponin level elevation. Following the demonstration CMR also plays an equally important role in the exclusion of of unobstructed coronary arteries on invasive angiography and other causes of troponin-positive chest pain and unobstructed impaired left ventricular function on transthoracic echocardi- coronary arteries, such as infarction due to recanalisation, ography, a diagnosis of myocarditis likely secondary to cloza- spasm or embolism . However, access to CMR is often lim- pine was reached. This report emphasizes the need for prompt ited and may be impractical as a screening test in all patients. recognition of myocarditis and immediate withdrawal of ther- Circulating biomarkers of myocardial injury, such as troponin, apy where clozapine-induced myocarditis is suspected. These represent a more feasible initial investigation and possible features appeared 2 days after starting clozapine therapy. approach for routine interval screening, which is relevant given However, it should be noted that symptoms are often non- that clinical presentation can be non-speciﬁc. speciﬁc with chest pain occurring in only half of all cases and Multiple potential mechanisms have been proposed for clinical presentation varying between Days 14 and 21 after clozapine-induced myocarditis . Hypersensitivity eosino- therapy initiation [8, 9]. In some cases, presentations may philic myocarditis is well documented with antibiotics (37%), indeed be delayed by several months requiring a high degree central nervous system agents (21%, primarily clozapine fol- of clinical suspicion for diagnosis . lowed by carbamazepine), vaccines (8%) and a range of other Received: November 13, 2017. Accepted: November 17, 2017 © The Author 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx096/4799002 by Ed 'DeepDyve' Gillespie user on 16 March 2018 16 A.S. Lota et al. Figure 1: Short axis image of the left ventricle for a patient with acute myocarditis using four different imaging sequences for detailed myocardial tissue characteriza- tion. (A) T2-STIR showing myocardial oedema in the mid-wall region of the inferoseptum (area of high signal intensity indicated by white arrow). (B) Late gadolinium enhancement showing replacement ﬁbrosis in the same region, importantly, with absence of sub-endocardial enhancement that would suggest myocardial infarc- tion. (C) T2 map for accurate quantiﬁcation of myocardial oedema. (D) Post-contrast T1 map for diffuse interstitial ﬁbrosis assessment. agents in 33% . An alternative mechanism may be linked to FUNDING increased circulating noradrenaline levels, which may result in Dr Lota is supported by BHF CRTF (FS/17/21/32712) and the cardiac dysfunction . This form of acute ‘catecholaminergic’ Alexander Jansons Foundation; Dr Halliday is supported by BHF myocarditis is difﬁcult to distinguish from Takotsubo cardio- CRTF (FS/15/29/31492). myopathy but are still considered distinct entities . However, it should be remembered that aetiology may be confounded by concomitant illicit drug use, and that both external insults may REFERENCES act synergistically to cause myocarditis. 1. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. 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Oxford Medical Case Reports – Oxford University Press
Published: Jan 1, 2018
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