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【正文】 Active or borderline myocarditis Nature history Complete recovery or death Inplete recovery or DCM DCM Normal LV function Myocarditis: an enigmatic disease! Dark side of the myocarditis Initial nonspecific symptoms Difficult to establish the diagnosis Etiology hard to find Complexity of pathogenesis Often refractory to conventional treatment Dark side of the myocarditis Initial nonspecific symptoms ? Similar to patients with sepsis, bronchiolitis, pneumonia, gastroenteritis, hepatitis, and renal failure etc. ? Aggressive fluid resuscitation may harm unstable patients ? Rapid progression in fulminant myocarditis Dark side of the myocarditis Difficult to establish the diagnosis ? Limited sensitivity and specificity of changes in CXR, ECG, cardiac enzyme (Troponin level: more sensitive) ? Echocardiogram: LV dysfunction, often regional ? Endomyocardial biopsy: as gold standard, but sensitivity 363% Dallas criteria Borderline myocarditis Active myocarditis Am J Cadiovasc Pathol 1987。 IgM, Enterovirus 70, Influenza A amp。les ? Heart: irregularly irregular beats, distant heart sound no murmur Physical Examination ? Abdomen: no hepatomegaly hypoactive bowel sound ? Extremities: freely movable cold and cyanotic poor capillary refilling Initial Lab Data CBC: WBC Hb Hct Plt 8840 % 160 K Seg %, Lym %, Eos % BCS: BUN Cre Na K Cl Ca 141 104 Initial Lab Data VBG: pH pCO2 pO2 HCO3 BE + Cardiac enzyme: CPK(U/L) CKMB Troponin I (ng/ml) 1040 CRP: mg/dl Initial Lab Data EKG (9/12): Initial Lab Data EKG (9/12): Initial Lab Data EKG (9/12): Initial Lab Data Echocardiogram (9/12): ? LV enlargement ? LVEF 45% ? Muscular VSD ? Mild MR, TR, PR Echocardiogram (9/12) Course and Treatment Management ? For cardiogenic shock: Dopamine, Dobutamin, Primacor, Lasix ? For ventricular arrhythmia: Amiodarone, Lidocaine, MgSO4 ? For myocarditis: IVIG, Consider extracorporeal membranous oxygenator (ECMO) support
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