p060206a Resident Report Volume 5, Number 32; April 21, 2006

Volume 5, Number 32; April 21, 2006

20-year-old African-American male with neck pain & 1 week rash.

Recommended reading:

Incidence and follow-up of inflammatory cardiac complications after smallpox vaccination.
Clinical outcome and left ventricular function 23 years after acute coxsackie virus myopericarditis.
Acute myopericarditis. A long-term follow-up study.
Postviral myopericarditis associated with the influenza virus; report of eight cases.

Patient: Young male presented with a pruritic rash and neck pain. Investigation revealed thrombocytopenia, cardiomegaly, and a CPK of > 1600. Cultures were negative. Diagnosis: myopericarditis of unknown etiology.

Session Handout:

Clinical Question:

1) What is the long-term outcome of acute myopericarditis of unknown etiology?

Readings:

Link Directly to Fulltext Article at Science Direct

<1>

Unique Identifier [PMID]: 15234435

Authors: Eckart RE. Love SS. Atwood JE. Arness MK. Cassimatis DC. Campbell CL. Boyd SY. Murphy JG. Swerdlow DL. Collins LC. Riddle JR. Tornberg DN. Grabenstein JD. Engler RJ. Department of Defense Smallpox Vaccination Clinical Evaluation Team.

Institution: U.S. Army Medical Command, Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200, USA. Robert.Eckart@us.army.mil

Title: Incidence and follow-up of inflammatory cardiac complications after smallpox vaccination.[see comment]. [Review] [22 refs]

Source: Journal of the American College of Cardiology. 44(1):201-5, 2004 Jul 7.

Abstract: OBJECTIVES: The purpose of this study was to assess the follow-up of patients with vaccinia-associated myocarditis. BACKGROUND: With the threat of biological warfare, the U.S. Department of Defense resumed a program for widespread smallpox vaccinations on December 13, 2002. One-year afterwards, there has been a significant increase in the occurrence of myocarditis and pericarditis among those vaccinated. METHODS: Cases were identified through sentinel reporting to military headquarters, systematic surveillance, and spontaneous reports. RESULTS: A total of 540,824 military personnel were vaccinated with a New York City Board of Health strain of vaccinia from December 2002 through December 2003. Of these, 67 developed myopericarditis at 10.4 +/- 3.6 days after vaccination. The ST-segment elevation was noted in 57%, mean troponin on admission was 11.3+/- 22.7 ng/dl, and peak cardiac enzymes were noted within 8 h of presentation. On follow-up of 64 patients (96%) at a mean of 32 +/- 16 weeks, all patients had objective normalization of echocardiography, electrocardiography, laboratory testing, graded exercise testing, and functional status; 8 (13%) reported atypical, non-limiting persistent chest discomfort. CONCLUSIONS: Post-vaccinial myopericarditis should be considered in patients with chest pain within 30 days after smallpox vaccination. Normalization of echocardiography, electrocardiography, and treadmill testing is expected, and nearly all patients have resolution of chest pain on follow-up. [References: 22]

Publication Type: Journal Article. Review.

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Unique Identifier [PMID]: 2311617

Authors: Remes J. Helin M. Vaino P. Rautio P.

Institution: Department of Medicine, Kuopio University Central Hospital, Finland.

Title: Clinical outcome and left ventricular function 23 years after acute coxsackie virus myopericarditis.

Source: European Heart Journal. 11(2):182-8, 1990 Feb.

Abstract: The clinical outcome of 18 patients, who presented with a Coxsackie virus myopericarditis in 1965, was evaluated 23 years later. Five patients had died, two of them had had heart failure. Thirteen patients and 23 healthy control subjects underwent exercise testing with gas exchange analysis. Left ventricular (LV) peak filling rate (PFR) was estimated by digitized M-mode echocardiography. Left ventricular ejection fraction was measured at rest and during exercise by radionuclide angiography. All patients were free of cardiac symptoms. Their clinical examination and the chest X-ray were normal. Peak oxygen consumption was not decreased in the patient group compared with the control group. PFR was significantly lower in the patient group than in the control group, 10.2 +/- 0.4 vs 13.2 +/- 0.4 cm s-1, P less than 0.001 (mean +/- SEM). LV ejection fraction was normal at rest in all patients (58 +/- 1%). An abnormal LV ejection fraction response to exercise was observed in two patients. Our data indicate that long-term prognosis after acute Coxsackie virus myopericarditis is good in a majority of patients.

Publication Type: Journal Article.

<4>

Unique Identifier [PMID]: 1014166

Authors: Sanner E. Sigurdsson G. Gislasson D. Gudbrandsson B. Stefansson M.

Title: Acute myopericarditis. A long-term follow-up study.

Source: Upsala Journal of Medical Sciences. 81(3):167-73, 1976.

Abstract: A follow-up study was made of 29 patients aged 21 to 45 years, some 15-158 months after acute myopericarditis. The mean follow-up period was 72.9 months. The follow-up investigation included recording of history, physical examination, laboratory tests, radiologic examination of the heart and lungs and electrocardiography. All but one of the patients were fit for fulltime work. Nine had residual cardiac symptoms, but the physical examination was negative in all but 2 of them. One patient had chronic cardiac insufficiency and hepatic enlargement. Another had sinus tachycardia and cardiac enlargement of moderate degree and impaired working capacity in relation to heart size. Cardiac murmurs without clinical significance were audible in three cases. The resting ECG was pathologic in only 6 cases. Orthostatic ECG evoked ECG abnormalities in 6 more cases. Exercise tolerance tests showed reduced working capacity in relation to heart volume in 5 of the 29 cases (17%). Four of these 5 patients had cardiac enlargement. There was thus good correlation between increase in heart volume and reduction of physical capacity. The prognosis in regard to cardiac function was good, as was also found in other comparable series in which the observation time was somewhat shorter.

Publication Type: Journal Article.

Link Directly to Fulltext Article at Science Direct

<7>

Unique Identifier [PMID]: 13661089

Authors: ADAMS CW.

Title: Postviral myopericarditis associated with the influenza virus; report of eight cases.

Source: American Journal of Cardiology. 4(1):56-67, 1959 Jul.

Publication Type: Journal Article.