Myocarditis in newborns: causes, symptoms and treatment methods. Myocarditis. Causes and pathogenesis of myocarditis. Symptoms of myocarditis in adults. Myocarditis in children. Acute, subacute and chronic myocarditis Myocarditis in children: symptoms and treatment

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What is myocarditis?

In order to understand what myocarditis is, you need to know the structure and functions of the heart. Heart is a muscular organ that ensures the delivery of oxygen to all tissues and organs of the body. This body consists of four main sections ( cameras) - left ventricle, left atrium, right ventricle and right atrium. The chambers are separated from each other by fibrous partitions. The heart can also be conventionally divided into left and right sections.

Damage to these departments is accompanied by heart failure. Therefore, if the left chambers of the heart are affected ( mainly the ventricle), then they talk about left heart failure, if the right part - about right heart failure.

In the structure of the walls of the heart, there are three main layers - outer, intermediate and inner. The intermediate middle layer is called the myocardium. This is the most powerful layer of the heart and is represented by striated cardiac tissue. This tissue is not found anywhere in the body. Myocardial cells are called cardiomyocytes.

Etiology ( origin) myocarditis

Depending on the etiology, there are many types of myocarditis. However, some experts conditionally divide all myocarditis only into rheumatic and non-rheumatic. The first include damage to the heart muscle during rheumatic fever ( or rheumatism), to the second – all others. The main difference between these two groups is that with rheumatic carditis there is damage to both the myocardium and endocardium ( inner lining of the heart). The consequence of this is damage to the heart valves with further development of valvular insufficiency.

Causes of myocarditis

Cardiotoxic drugs include:

• Cyclophosphamide and other cytostatics from the group of alkylating compounds. When treated with cyclophosphamide, the heart becomes the main target. Acute heart damage can develop already in the first week of treatment.
• Rituximab and other drugs from the monoclonal antibody category. This group of drugs is currently actively used in the treatment of arthritis. However, it also has increased specificity for cardiac cells. When treated with rituximab, edema, infiltration, and damage to small vessels develop in the myocardium. The most common side effect of monoclonal antibody treatment is a sharp decrease in blood pressure ( acute hypotension) and arrhythmias.
• Interleukins also provoke heart rhythm disturbances ( arrhythmias, blockades) and hemodynamic disorders, in the form of decreased blood pressure. Interleukins also represent a new direction in pharmacotherapy - they are used in the treatment of many rheumatic diseases.
• Fluorouracil is a drug from the group of antimetabolites, which is widely used in the treatment of malignant neoplasms ( cancer). During treatment with this drug, constant monitoring of the electrocardiogram is recommended, since fluorouracil can cause spasm of the coronary vessels and provoke thrombosis. The result of this is a decrease in blood supply to the myocardium, that is, the development of ischemia.
• Sutent is an antitumor drug from the group of tyrosine kinase inhibitors. Can cause cardiac arrest, severe arrhythmias and blockades. However, changes that occur in the heart during treatment with this drug can disappear if the drug is discontinued in a timely manner.
• Pimozide, haloperidol and other antipsychotic drugs. They also cause changes in the functioning of the heart. Basically, these changes affect the heart rhythm and manifest themselves in blockages.

Pathogenesis of myocarditis

The mechanisms of myocarditis are:

• direct toxic damage to cardiomyocytes ( myocardial cells) – observed in alcoholic and toxic myocarditis;
• nonspecific damage due to generalized inflammation - characteristic of some systemic diseases;
• damage to myocardial cells during systemic infection – observed with viral myocarditis;
• cellular damage by immunological factors – observed when exposed to allergic factors.

Stages of myocarditis

The stages of myocarditis include:

• First stage– lasts from several hours to several days, depending on virulence ( aggressiveness) pathogen. It begins with the virus entering the body and fixating on myocardial cells. At first it clings to the surface of the cell, but very quickly penetrates into it. In response to this, the body activates its own reserves and produces antibodies to the virus. After the virus leaves the cell, antibodies and immune complexes continue to circulate in the body.
• Second stage ( autoimmune) – characterized by activation of inflammatory processes. Edema of the intercellular substance develops, and small vessels of the heart are affected. All this leads to the development of oxygen deficiency or myocardial hypoxia. Heart cells are very sensitive to lack of oxygen, so they begin to die quickly. Under conditions of oxygen starvation, the processes of collagenosis are activated ( synthesis of collagen fibers). Subsequently, collagen fibers begin to replace normal myocardial tissue. This phenomenon is called cardiosclerosis.
• Third stage– or stage of recovery. It is characterized by a decrease in cellular infiltrate, edema, and restoration of cardiac activity. The consequences of this stage depend on the degree of change that occurred in the second stage. Thus, the more extensive the growth of connective tissue occurs, the more myocardial contractility decreases. With massive cardiosclerosis, there is a decrease in cardiac function up to its complete loss.

Myocarditis in adults

Symptoms ( signs) myocarditis

• shortness of breath ( worsens after exercise and in a lying position);
• too frequent or, conversely, slow heartbeat;
• extrasystole ( type of heart rhythm disorder);
• weakness, fatigue, irritability;
• pale skin, sometimes with a bluish tint;
• swelling of the lower extremities, swelling of the neck veins ( at advanced stages);
• chest pain that is not relieved by nitroglycerin ( cure for heart pain).

The type of disease also affects the type and severity of symptoms. Thus, rheumatic myocarditis is characterized by a calm course without pronounced symptoms. Sometimes patients are bothered by chest pain without clear localization, mild shortness of breath that occurs after intense physical exertion. Idiopathic myocarditis, on the contrary, is characterized by a severe course with clearly defined symptoms. Patients suffer from severe heart pain, irregular heartbeat, and swelling of the legs.

Sometimes myocarditis occurs without any symptoms at all. As a rule, an asymptomatic course is typical for those cases when the disease develops on its own ( primary myocarditis), and not against the background of any pathology.

Variants of manifestation of myocarditis symptoms
As a rule, in the complex of symptoms that worry a patient with myocarditis, there are always several signs that prevail over the rest. Based on this, in medical practice there is a classification of the symptoms of this disease.

The following variants of manifestation of myocarditis symptoms are distinguished:

• Painful. It manifests itself as pain in the heart area, which is of a burning and/or squeezing nature.
• Arrhythmic. Patients experience interruptions in the functioning of the heart, namely its freezing, which alternates with increased heartbeat.
• Pseudovalve. This option is characterized by mild or moderate shortness of breath, an unknown type of pain in the heart, and general weakness.
• Thromboembolic. Patients are concerned about shortness of breath, a bluish tint to the skin on the fingers, in the area of ​​the nasolabial triangle.
• Decompensation. It manifests itself as painful rapid heartbeat, tinnitus, and decreased blood pressure.
• Mixed. In this case, myocarditis manifests itself in several of the above symptoms.
• Asymptomatic. This option is characterized by the absence or weak manifestation of any signs of the disease.

Pain due to myocarditis

Pain due to myocarditis occurs independently, without the influence of any external factors ( physical activity, stress). Unlike chest discomfort with other cardiac pathologies ( for example, with angina pectoris), pain due to myocarditis does not go away after taking nitroglycerin and other similar drugs.

Extrasystole

Classification of extrasystole
Extrasystole is classified according to such parameters as impulse localization, rhythm ( alternation of normal and extraordinary contractions), time of occurrence of extrasystoles.

The localization of the impulse refers to the part of the heart ( atrium or ventricle) in which the contraction occurs. Depending on this criterion, extrasystoles can be atrial, ventricular or atrioventricular. The most life-threatening is ventricular extrasystole, which has the most severe symptoms. With atrial or atrioventricular extrasystole, heart rhythm disturbances can only be detected during instrumental examination ( for example, with an electrocardiogram).

Heart rhythm during extrasystole, that is, the alternation of normal and extraordinary contractions of the heart muscle, can have several variants of manifestation.

The following heart rhythms are distinguished in this pathology:

• bigeminy ( the appearance of extrasystoles after every normal contraction of the heart);
• trigeminy ( the appearance of an extraordinary impulse after 2 normal contractions);
• quadrigeminy ( the appearance of extrasystole after 3 normal contractions).

How does extrasystole manifest?
When an extrasystole occurs, the patient feels a strong heartbeat, which may be accompanied by a feeling of anxiety or even panic. When describing their subjective sensations, patients use such definitions as “tumbling” or “turning over” the heart, a complete cessation of heart contractions for a while, a strong blow to the chest from the inside. At the same time, extrasystoles can rarely be determined by measuring the pulse, since only those impulses that occur during normal contractions of the heart reach the arteries.

In addition to subjective sensations during extrasystole, dizziness, headaches, and shortness of breath are observed, accompanied by a feeling of lack of air. When examining a patient, swollen, pulsating veins may be detected in the neck area. Frequent heart rhythm disturbances provoke deterioration of blood supply, which can cause nervous tics, severe headaches, and fainting.

Is myocarditis dangerous?

Complications ( consequences) myocarditis

The following are possible complications of myocarditis:

• cardiomegaly;
• myocardial cardiosclerosis;
• heart rhythm disorder;
• intracardiac thrombi;
• congestive heart failure.

Between the pericardium and myocardium there is a cavity ( pericardium), filled with fluid, which provides sliding movements to the heart during contraction. When the outer shell is inflamed, this cavity is filled with pathological contents ( which cells secrete during inflammation). Normally, this cavity holds no more than 30 milliliters of fluid, but with pericarditis the volume can increase 10 times. An enlarged heart sac puts stress on the heart, impeding blood flow, which in advanced cases can cause death. Also, filling this cavity with pathological contents can lead to pericardial rupture.

Like other inflammations, pericarditis can have acute and chronic forms. In the first case, the pericardial sac quickly fills with pathological contents, which causes severe circulatory disturbances and the threat of pericardial rupture. In chronic pericarditis, the cavity fills slowly, which reduces the intensity of complications that arise.

Based on the type of fluid that accumulates in the heart sac, pericarditis can be exudative or purulent. There is also a fibrous form of pericarditis, in which the pericardial cavity is filled not with fluid, but with fibrin ( protein tissue). Over time, the walls of the heart sac grow together, which increases the load on the heart and causes various complications.

The symptoms of pericarditis depend largely on the form ( purulent, fibrous, exudative) inflammation. With chronic inflammation of the outer lining of the heart, the symptoms appear more blurred, with an acute form - more vividly.

The following signs of pericarditis are distinguished:

• Pain in the heart area. Unlike pain with myocarditis, which occurs without the influence of external factors, with pericarditis the pain intensifies when lifting the head or torso up, when coughing, or when swallowing water or food. With the fibrotic form, patients complain of dull, pressing pain, with the exudative form – of sharp, sharp pain.
• Hiccups. This symptom is characteristic of all forms of pericarditis. The cause of hiccups is inflammation of the nerve located next to the pericardium.
• Difficulty swallowing. It is observed in the later stages of pericarditis and develops due to the fact that the heart sac begins to put pressure on the esophagus.
• Swelling of veins. With the exudative form, the veins enlarge on the patient’s neck, with purulent pericarditis - on the surface of the chest.

Cardiomegaly is a latent syndrome, that is, this problem does not have any specific symptoms. Therefore, pathology is detected only during examination. As with myocarditis, patients experience heart pain and shortness of breath, and heart rhythm is disturbed. Patients' resistance to both physical and mental stress decreases.

Therapy for cardiomegaly in some cases involves surgery. The purpose of the operation may be the implantation of special devices to regulate cardiac activity, prosthetic heart valves, bypass surgery ( expansion with a probe) cardiac blood vessels. In the absence of timely medical intervention, cardiomegaly can cause stroke, heart attack and other dangerous conditions.

Myocardial cardiosclerosis
With this pathology, the myocardial muscle tissue begins to be replaced by connective tissue ( fibrous dense fibers). Myocardial cardiosclerosis ( myofibrosis, cardiac sclerosis) always develops as a secondary disease against the background of myocarditis of bacterial, viral or allergic origin. Inflammation of the heart muscle entails pathological changes in the structure of the myocardial muscle tissue, which provokes the growth of fibrous cells that replace normal fibers. Healthy myocardial tissue is highly elastic, which allows the heart to contract. The appearance of fibrous areas leads to a deterioration in the contractile function of the heart, which provokes various types of arrhythmias.

Signs of myocardial cardiosclerosis are:

• feeling of heaviness and pain ( pressing) in the chest;
• paroxysmal cough;
• shortness of breath, feeling of lack of air;
• increased heart rate;
• constant fatigue, decreased performance.

Heart rhythm disorder
With prolonged myocarditis, various heart rhythm disturbances develop ( arrhythmias), which appear more and more often over time. This leads to the fact that maintaining a normal heartbeat becomes impossible without taking medications.

The following heart rhythm disorders may develop against the background of myocarditis:

• Tachycardia. In this condition, the heart begins to beat faster than usual, exceeding the norm, which is 90 beats per minute. A person feels a strong heartbeat, which may be accompanied by dizziness and anxiety.
• Flickering arrhythmia. With this pathology, the atria of the heart begin to contract chaotically ( flicker), and the contraction frequency can reach 300 per minute. The patient feels a strong “fluttering” of the heart, trembling, and fear. In some cases, prolonged attacks of atrial fibrillation can lead to fainting.
• Bradycardia. With this disorder, the contraction frequency is less than 60 beats per minute. Bradycardia is accompanied by severe weakness, the appearance of cold sweat, and semi-fainting.
• Heart block. With this problem, the heart rate is reduced to critical levels, which can lead to fainting, and in severe cases, sudden death.

Plugs can be localized in arteries, vessels or capillary beds. Blood clots are made from blood cells ( platelets, leukocytes, erythrocytes) and fibrin ( connective fibers). Blood clots can be static or moving. In the first case, they are attached to the wall and may have a stalk, which is why they resemble a polyp. Mobile formations move freely and are most often localized in the left atrium.

The symptoms that accompany an intracardiac thrombus largely depend on whether it moves or not. Thus, with immobile formations, people rarely detect any pathological changes in their condition. Sometimes the heartbeat may increase and shortness of breath may appear. With mobile blood clots, patients complain of frequent attacks of tachycardia, which are accompanied by the appearance of sticky cold sweat, sudden paleness or blue discoloration of the lips and fingers. Cardiac thrombosis is a serious complication of myocarditis, which, if left untreated ( often involves surgery) can cause death.

Congestive heart failure
With this pathology, the heart cannot cope with pumping the proper volume of blood necessary to ensure vital processes. Congestive heart failure ( ZSN) may be right-handed ( the functioning of the right ventricle is impaired) or left-handed ( left ventricular dysfunction). The disease develops in stages, going through 3 main stages.

The following features of the development of heart failure are distinguished:

• First stage. Manifested by shortness of breath, acrocyanosis ( blue fingers, nasolabial triangle), general weakness, cardiac arrhythmia. With right-sided heart failure, a person is also periodically bothered by pain in the area of ​​the right hypochondrium, swelling of the legs, and moderate thirst. In left-sided CHF, the main symptoms include problems such as a dry cough, expectoration of bloody mucus, and a feeling of shortness of breath at night.
• Second stage. All previous symptoms of the disease intensify and begin to bother the patient more often. Often at this stage, heart failure goes from unilateral to bilateral, since the healthy ventricle is also involved in the pathological process. In addition to the heart, the disease also affects other organs, most often the liver and lungs. Patients note dry or moist wheezing, asthma attacks, and pain in the liver area. Palpation reveals an enlarged liver. The examination reveals an accumulation of fluid in the peritoneum ( ascites), in the pleural cavity ( hydrothorax).
• Third stage. The final stage is characterized by a worsening of all the symptoms that accompanied the previous stages. To the existing problems is added the deterioration of the functionality of other body systems.

Prognosis for myocarditis

If myocarditis was aggravated by heart failure, then with adequate therapy, half of the patients experience a significant improvement in their condition until complete recovery. Number of patients achieving remission ( relief of symptoms), is 25 percent. In the remaining quarter of patients, the condition steadily worsens, even with treatment.

Giant cell myocarditis has an extremely unfavorable prognosis, since in the absence of surgical intervention the mortality rate reaches almost 100 percent. With diphtheria inflammation of the heart, the number of deaths varies from 50 to 60 percent. In most cases, the only effective treatment option for patients with these forms of myocarditis is heart transplantation.

Myocarditis in children

As in adults, viruses are the main cause of myocarditis in children. In children of the younger age group, the phenomenon of carriage of the virus is also observed, which significantly increases the risk of developing viral myocarditis.

The causes of myocarditis in children are:

• Viruses. The Coxsackie virus accounts for more than 50 percent of cases. The clinical picture of the disease is often very blurred, which makes diagnosis difficult. The disease develops after an enterovirus infection.
• Bacteria. Bacterial myocarditis is typical for infants. Their disease develops against the background of sepsis. In children of the younger age group ( up to 3 years) myocarditis can develop against the background of osteomyelitis. Bacteria that cause myocarditis include streptococci, pneumococci, diphtheria bacillus, and salmonella.
• Protozoa. This category of causes of myocarditis in children is less common than in adults. In this case, myocarditis develops against the background of toxoplasmosis or amoebiasis.

Development mechanism ( pathogenesis) myocarditis in children

In children, a distinction is made between congenital and acquired myocarditis. In the origin of the first group of myocarditis, maternal diseases, intrauterine infections, and placental pathologies play a large role. In the origin of acquired myocarditis, external factors play a major role.

Congenital myocarditis in children

Early congenital myocarditis
Early congenital myocarditis develops at 5–7 months of intrauterine development, as a result of which the child is already born with symptoms of the disease. During this period, the structure of the cardiac membranes - the pericardium, myocardium, and endocardium - is disrupted. Very quickly they are replaced by connective tissue, which leads to impaired contractility of the heart.

As a rule, children with congenital myocarditis are born with a deficiency of weight. The developmental delay continues after birth - children have difficulty gaining weight, and they are also stunted in growth. No specific cardiac symptoms are initially observed. Basically, nonspecific signs of heart failure attract attention - pallor of the skin, combined with cyanosis ( cyanosis), increased sweating. Such children, as a rule, are apathetic, passive, and get tired quickly. Congenital myocarditis quickly decompensates if the child becomes ill. It could be a common cold or pneumonia. In this case, shortness of breath, swelling, cough, and moist rales in the lungs appear ( due to stagnation in the pulmonary circulation). The examination reveals an increase in the size of the heart and muffled heart sounds.

The main diagnostic methods are electrocardiogram ( ECG), echocardiography ( EchoCG), chest x-ray. X-rays reveal an enlarged child’s heart, mainly due to the left side of the heart. Echocardiography shows a decrease in ejection fraction of up to 45 percent. Ejection fraction is the percentage of blood volume that is ejected from the heart into the blood vessels during one contraction. Simply put, this is the main indicator of the efficiency of the heart. Normally it should be 60 percent. A decrease in this indicator to 45 percent indicates severe heart failure. Therefore, the prognosis for early congenital myocarditis is disappointing. Most children die in the first months of life. With unexpressed changes, life expectancy can reach 10–15 years.

Late congenital myocarditis
Late congenital myocarditis develops after 7 months of intrauterine development, that is, during the third trimester of pregnancy.
In this case, children can be born both with the consequences of myocarditis and with the current disease. The clinical picture reveals rhythm and conduction disturbances in the form of blockades and arrhythmias. Children are lethargic, apathetic, and do not eat well. Upon examination, attention is drawn to frequent and shallow breathing, shortness of breath, pale skin, and cyanosis of the nasolabial triangle. Such children often experience damage to the central nervous system in the form of seizures. The combination of damage to the heart and nervous system often indicates a viral origin of the disease ( Coxsackie viruses are often involved).

If the process is acute, then laboratory blood tests show signs of inflammation. Regardless of the stage of the process, changes are noted on the electrocardiogram, x-ray, echocardiogram. The prognosis of late congenital myocarditis is more favorable and depends on timely medical care and the etiology of the disease.

Acquired myocarditis in children

Myocarditis after tonsillitis

With this pathology, a chronological pattern is revealed between angina and the appearance of the first signs of myocarditis. The clinical picture is very diverse and is characterized by a predominance of general intoxication syndrome. Isolated myocarditis after tonsillitis is rare. As a rule, it occurs in conjunction with other diseases, most often acute rheumatic fever. This is a systemic disease primarily affecting the cardiovascular system, which occurs in children from 7 to 15 years of age. Rheumatic fever develops against the background of an increased immune response to the presence of beta-hemolytic streptococcus in the body. This microorganism is the causative agent of purulent sore throat in 90 percent of cases. In addition to damage to the cardiovascular system, neurological symptoms and a ring-shaped rash are also noted.

As a rule, rheumatic fever debuts after 7–10 ( less often 14) days after a sore throat. The first symptoms are weakness, malaise, and a sharp increase in temperature to 38 degrees. Damage to the heart in this case is conventionally called rheumatic carditis and is manifested by shortness of breath, pain in the heart area, and rapid heartbeat. The difference between rheumatic carditis is that it occurs not only with myocardial damage ( the heart muscle itself), but also with the involvement of the connective tissue membrane of the heart in the pathological process ( endocardium). This is followed by pain in the joints, ring-shaped erythema, chaotic uncontrolled movements of the arms and legs ( chorea). Despite such a varied picture of the disease and its apparent seriousness, with timely treatment, changes in rheumatic fever are completely reversible. However, if treatment is delayed, changes in the heart can cause further heart failure. Basically, heart failure after tonsillitis is caused by damage to the mitral and/or aortic valve.

Diphtheria myocarditis

Myocarditis is a fairly specific symptom and/or complication of diphtheria. In turn, diphtheria is an acute infectious disease caused by Loeffler's bacillus. It mainly affects the upper respiratory tract - nasopharynx, larynx, lungs. As a rule, the disease is extremely severe. The reason for this is the action of the toxin that is secreted by the diphtheria bacillus. It is the toxin that affects the internal organs in diphtheria, sometimes leading to multiple organ ( multiple) insufficiency.

Diphtheria myocarditis occurs in the clinical picture of diphtheria in 25–30 percent of cases. Myocardial damage also occurs “due to” the action of diphtheria toxin. When the toxin enters the heart muscle, it first of all affects the conduction system of the heart and the nerve plexuses. This is explained by the fact that diphtheria toxin has increased sensitivity ( tropism) to the nervous system.
Damage to the conduction system of the heart causes cardiac arrhythmia, which is manifested by arrhythmias and blockades. Patients complain of rapid heartbeat, shortness of breath, and weakness. Pain in the heart also quickly develops, and the heart increases in size.

The main method for diagnosing diphtheria myocarditis is an electrocardiogram. It shows a displacement ( deprivation or elevation) ST segment, which indicates insufficient blood supply to the heart muscle ( that is, about ischemia).

Treatment consists of administering anti-diphtheria serum. Symptomatic treatment is also carried out, in which

Myocarditis is inflammation of the myocardium (heart muscle). The disease is quite widespread among children of any age, but is more often registered in 4-5 year old children (mainly boys) and in adolescents.

Causes of myocarditis

There are congenital and acquired myocarditis. The causes of the development of myocarditis are very diverse and are caused by the influence of various factors.

Infections:

• bacterial (for streptococcal infection, meningococcal infection, brucellosis, etc.);
• viral (caused by enteroviruses, viruses, etc.);
• fungal (for aspergillosis, actinomycosis, etc.);
• spirochetosis (with leptospirosis, Lyme disease, borreliosis);
• rickettsial (for typhus, Q fever);
• caused by protozoa (malaria, leishmaniasis, toxoplasmosis, etc.).

• with trichinosis;
• cysticercosis;
• echinococcosis, etc.

Toxic and chemical factors:

• snake bite, ;
• exposure to carbon monoxide, mercury, arsenic, etc.;
• drug use and (in adolescents).

Physical factors:

• ionizing radiation;
• hypothermia;
• overheating.

Effects of certain medications:

• sulfa drugs;
• vaccines and serums;
• spironolactone, etc.

In addition to those listed, predisposing factors are also autoimmune And allergic diseases.

As can be seen from the above, the development of myocarditis can be caused by any infection, but viral diseases are dominant in children, among which myocarditis is most often caused by adenoviruses, Coxsackie enteroviruses, and influenza viruses.

Of the bacterial infections, myocarditis most often develops with, and diphtheria.

Often children also experience myocarditis when exposed to toxins and congenital (developed in utero as a result of infection of a woman during pregnancy). With autoimmune myocarditis, the child’s body produces antibodies to its own heart muscle cells, which destroy the myocardium.

If we consider the cause of myocarditis depending on the age of the child, then at an early age the disease is of viral, bacterial and toxic origin, and at an older age the development of myocarditis in infectious-allergic diseases is more typical.

Autoimmune myocarditis can occur with delayed-type allergic reactions, but can also be an independent disease.

In some cases, the cause of myocarditis cannot be established, and then they speak of idiopathic myocarditis.

Symptoms

There is no clinical symptom that would allow one hundred percent accuracy to diagnose myocarditis. Myocarditis in children is characterized by severity and a rapid increase in symptoms.

Clinical manifestations of myocarditis in childhood may differ slightly depending on:

• the reasons that caused myocarditis;
• the depth of damage and the extent of the inflammatory process in the heart muscle;
• flow option.

There are such forms of myocarditis:

• according to the course: acute, subacute and chronic;
• according to the prevalence of the inflammatory process: isolated (or focal) and diffuse;
• by severity: mild, moderate and severe;
• according to clinical manifestations: typical, erased, asymptomatic forms.

Some scientists distinguish, in addition to acute, hyperacute, or fulminant (fulminant) myocarditis, chronic active and chronic persistent variants of the course of the disease.

Inflammation of the myocardium alone is rare. Usually, in addition to the muscle, inflammation spreads to both the inner lining of the heart () and the outer lining (). In this totality, changes are found in every third child with myocarditis at an early age. The prevalence of inflammation affects the clinical manifestations of the disease.

During the newborn period (4 weeks after the birth of the baby) congenital myocarditis is severe and has the following manifestations: the baby’s skin is pale with a grayish tint; weakness is expressed (the child gets tired quickly during feeding); weight increases very slowly.

The baby's hands and feet are cold. The child is lethargic. The doctor notes an expansion of the boundaries of the heart and an increase in the size of the liver. The child is lagging behind in physical development.

A dry cough may appear. In severe cases of the disease, edema may appear in the alveoli of the lungs; in this condition, the doctor will be able to listen for moist rales. In critical cases, it develops and can be fatal.

In older age In children, myocarditis occurs in acute, subacute and chronic recurrent forms, and has a more benign course. After an infection, myocarditis does not manifest itself in any way for 2-3 weeks.

Then weakness, increased fatigue, pale skin, and some weight loss appear. Body temperature may remain normal or rise slightly. Children may experience pain in muscles and joints, and sometimes abdominal pain.

Children of preschool and school age experience pain in the heart and shortness of breath. Initially, they appear only during physical activity, and subsequently - at rest. Heart pain, although not pronounced, is long-lasting and difficult to relieve with medications.

The child has sleep disturbances, increased fatigue, and fainting. Some children may experience digestive problems.

An increase in heart rate (and sometimes a decrease in heart rate due to conduction disturbances) and expansion of the boundaries of the heart are observed less frequently. But on the other hand, cardiac activity, swelling in the lower extremities, and enlarged liver may appear.

Idiopathic myocarditis differs in severity.

Diffuse myocarditis is characterized by a greater decrease in myocardial contractility, which is manifested by the development of heart failure. In a focal process, damage to the conduction system is more typical, which manifests itself clinically.

Diagnostics

Various methods are used to diagnose myocarditis:

1. Interview of the child (if age allows) and parents: the doctor finds out and details the complaints, the timing of their appearance, the presence of a previous illness, etc.
2. Examination of the child allows the doctor to detect pallor and cyanosis of the skin, characteristic of myocarditis; expansion of the boundaries of the heart; heart murmurs; identify increased heart rate and rhythm disturbances; the presence of edema, shortness of breath, wheezing in the lungs; determine the size of the liver and spleen; check the height and weight indicators and their correspondence to the child’s age, etc.
3. A clinical blood test may show an increase in the number of leukocytes, leukocyte formula indicators, acceleration of ESR, an increase in the number of eosinophils and basophils in allergic reactions.
4. A biochemical blood test makes it possible to determine the activity of myocardial enzymes, detect C-reactive protein, determine protein fractions, etc.
5. A serological blood test can detect antibodies to a previous viral infection.
6. Electrocardiography (ECG) in the usual way or by the method of daily monitoring (Holter method) allows you to detect disturbances in heart rhythm and conduction in the heart muscle.
7. makes it possible to identify the expansion of the cavities of the heart, condition, blood flow speed, etc.
8. X-ray of the chest organs may show expansion of the borders of the heart, stagnation of blood in the lungs.
9. In rare, difficult-to-diagnose cases, a biopsy of the heart muscle is performed to determine the presence and extent of the inflammatory process in the myocardium.

Treatment

Treatment of acute myocarditis is carried out in a hospital. Strict bed rest is prescribed, the timing of which is determined individually. Bed rest is necessary even in the absence of manifestations of heart failure. In severe cases, oxygen therapy is used.

Treatment of myocarditis should be comprehensive. Specific treatment for myocarditis has not been developed. The main direction is the treatment of the underlying disease that caused myocarditis.

The main components of complex therapy for myocarditis:

• In the case of the bacterial nature of the infection, antibacterial drugs are used: antibiotics (most often Doxycycline, Monocycline, Penicillin, Oxacillin are used).
• For myocarditis caused by a viral infection, they use (Ribavirin, Interferon, Immunoglobulins). Cardio Transfer Factor is often prescribed: an immunomodulator that has no side effects or contraindications. The drug is approved for use from the moment the child is born.

Intravenous administration of gammaglobulin increases the survival rate of children and improves the recovery of myocardial function.

• Complex treatment includes: salicylates, pyrazolone drugs (Voltaren, Indomethacin, acetylsalicylic acid, Butadione, Metindol, Brufen, Hydroxychloroquine).

These drugs are required in the treatment of myocarditis with a protracted or recurrent course. Some of these medications relieve heart pain. For persistent pain syndrome, Anaprilin can be prescribed in a minimal dosage.

• Hormonal drugs have a powerful anti-inflammatory and anti-allergic effect: . For severe myocarditis, Prednisolone, Hydrocortisone, Triamcinolone, Dexamethasone are used.

Hormonal therapy is indicated for severe heart failure, pericarditis, and autoimmune myocarditis. The dosage and duration of hormone use is determined individually. During treatment with hormonal drugs, medications are prescribed; it is recommended to consume foods rich in potassium (raisins, carrots, dried apricots, etc.).

• When heart failure develops after stopping the inflammatory process in the myocardium, digitalis preparations are used under ECG control. In case of severe heart failure, Dopamine and Dobutamine can be used.

• For edematous syndrome, they use (Hypothiazide, Novurit, Fonurit, Lasix), a fasting fruit-sugar diet.

• Complex treatment should include vitamin preparations, especially ascorbic acid and B vitamins. For anxiety, headaches, and sleep disturbances, symptomatic treatment is carried out.

• In case of cardiac arrhythmias, antiarrhythmic drugs are selected. For particularly persistent arrhythmias, a surgical treatment method is performed: transvenous cardiac pacing or implantation of a pacemaker.

For chronic recurrent myocarditis, after a hospital course of treatment, sanatorium treatment is recommended.

Diet

If you have myocarditis, you should provide your child with proper nutrition. In mild cases of the disease, it is recommended to limit carbohydrate intake (excluding baked goods, chocolate and limiting pasta, pancakes, and baked goods). You should not feed your child rich broths, fatty meats, smoked and spicy foods, or pickles.

Even fruits such as grapes, plums, hard pears and apples should not be given to a child with myocarditis.

What can you give? A sick child will benefit from the following products:

• lean beef and chicken;
• liver;
• fish (hake, cod, pollock, pike, pike perch);
• eggs (3 pieces per week) in the form of an omelet;
• any porridge;
• vegetables (carrots, potatoes, cauliflower, tomatoes, cucumbers, beets, parsley and lettuce).

Fermented milk products and milk are not prohibited. You can pamper your sweet tooth with marshmallows, marmalade, honey or jam (if you don’t have allergies). Soft varieties of fresh fruit and dried fruit are also allowed.

Prognosis and outcomes of the disease

With myocarditis, the prognosis depends on the age of the child and the underlying disease that caused myocarditis.

An unfavorable outcome is more often observed in early childhood and in newborns: among them there is a high mortality rate. Even if the child survives, pronounced sclerotic changes develop in the myocardium after the inflammatory process and chronic progressive heart failure, leading to the death of the child.

Bacterial myocarditis often ends in recovery, but viral myocarditis, as a rule, has an unfavorable outcome.

In preschool and school age, myocarditis has a benign course and often ends with complete recovery. In some cases, after the disease, cicatricial sclerotic changes in the myocardium are observed, which can lead to the development of heart failure.

In addition to cardiosclerosis, complications of myocarditis can include pericarditis, thromboembolism, cardiac arrhythmias, dilation of the heart cavities, and heart failure.

Chronic myocarditis in 50% of cases has a recurrent course with the development of chronic heart failure.

Myocarditis refers to diseases of an inflammatory nature that affect the heart muscle.

With this disease, infectious inflammation develops in the inner layer of the heart (myocardium), which is accompanied by the occurrence of irreversible complications.

Among children, myocarditis is most often diagnosed at the age of 4–5 years. The disease is accompanied by infiltration of immunocompetent cells and, in the absence of proper treatment, leads to the occurrence of heart failure.

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Causes

There are two types of myocarditis, which differ in the time of onset, namely:

In addition, the occurrence of viral myocarditis can be affected by such ailments as:

• polio;
• sore throat (tonsillitis);
• tuberculosis;
• diphtheria;
• viral hepatitis;
• adenoviruses;
• cytomegaloviruses;
• candidiasis;
• Lyme disease;
• typhus;
• toxoplasmosis.

Infectious myocarditis is most often diagnosed in children. Often, heart problems in children begin after streptococcal tonsillitis, meningococcal infection, scarlet fever and rheumatism.

The development of cardiac inflammation can be triggered by toxic and chemical factors, for example, a wasp or snake bite, poisoning with arsenic, carbon monoxide, mercury vapor, etc.

The cause of myocarditis in children is often helminthic infestations due to trichinosis, cysticercosis, etc. Physical factors, such as hypothermia, overheating or ionizing radiation, cannot be excluded.

In addition, the disease often develops due to certain medications, especially if they were taken for a long time and intensively.

Also, in addition to the above reasons, the occurrence of myocarditis is influenced by allergic and autoimmune diseases.

The leading clinical symptom of rheumatic myocarditis in children is pain in the thoracic region, localized mostly on the left side.

The presence of symptoms depends on the cause that provoked the inflammation, the prevalence of the pathological process and the severity of the course.

The type of myocarditis also affects the manifestation of the disease:

• fulminant inflammation;
• chronic course;
• acute myocarditis;
• chronically active.

The inflammatory process exclusively in the myocardium is quite rare. Often this pathology is accompanied by damage to the endocardium (inner lining of the heart muscle) and pericardium (outer). The larger the area of ​​spread of the disease, the more symptoms are observed.

With congenital myocarditis, in the first month of a baby’s life, there are the following signs of heart problems:

• pale or grayish skin tone;
• weakness and lethargy;
• rapid fatigue during feeding;
• poor weight gain;
• anxiety;
• swelling on the face.

Another noticeable symptom is shortness of breath and palpitations that appear in the child during bathing, bowel movements or changing clothes.

Myocarditis, which develops after an infection or against its background, is often accompanied by an increase in body temperature (up to 37.5 degrees), weight loss and refusal to eat.

In addition, the child exhibits the following symptoms:

• cardiopalmus;
• cyanosis of the skin;
• severe abdominal pain;
• passivity (refusal to play);
• constant fatigue;
• dyspnea;
• dry cough;
• fatigue.

Also, signs of heart pathologies include cold feet and hands in the baby. The physical development of a child with chronic myocarditis often does not correspond to his age. Older children may complain of joint and muscle pain that occurs both at rest and during physical activity.

If myocarditis in a child is accompanied by heart failure, then the main symptoms include:

• dizziness;
• headache;
• pre-fainting states;
• arrhythmias;
• loss of consciousness;
• digestive disorders;
• swelling of the lower extremities.

With diffuse myocarditis, the contractile function of the heart is impaired, which can provoke stagnation in the pulmonary and systemic circulation.

Diagnostics

To determine the presence of myocarditis and its complications, it is necessary to conduct a thorough diagnosis, which consists of three main methods:

• differential;
• laboratory;
• hardware room

If age allows, you should initially interview the child. It is important to find out as many of the symptoms that are bothering him as possible and when exactly they occur. It is also necessary to resort to interviewing parents to complement the clinical picture of the disease.

To determine skin changes characteristic of myocarditis, the initial examination should include a physical examination, as well as auscultation of the heart, lungs, and palpation of the liver.

The following symptoms indicate the presence of myocarditis:

• pale or bluish skin;
• expanded borders of the heart;
• extraneous noises and wheezing;
• heartbeat disturbance;
• dyspnea;
• liver enlargement;
• swelling;
• retardation in height and weight.

All these signs are significant indicators for laboratory tests and instrumental research methods. The first include taking blood to determine an increase in leukocytes, acceleration of ESR and accumulation of eosinophils and basophils if inflammation occurs due to an allergic reaction.

A biochemical blood test for myocardial inflammation indicates significant activity of myocardial enzymes, determines protein fractions and C-reactive protein. To detect antibodies to a recent viral infection, a serological test is performed.

Instrumental research methods help to exclude other possible pathologies and assess the degree of damage to the heart muscle.

Such diagnostics consists of the following methods:

Treatment

Treatment of childhood myocarditis is carried out strictly in a hospital setting. The child is prescribed bed rest and a special salt-free diet, compliance with which is monitored by medical staff.

In case of severe illness, which is accompanied by breathing problems, the patient is given oxygen therapy.

Treatment is prescribed depending on the main causative agent of the disease, the type of myocarditis and the presence of complications. Therapy must be comprehensive. It is important to take each drug at approximately the same time.

To better restore the myocardium and increase the chance of survival, intravenous administration of gammaglobulin is used.

Complex treatment of myocarditis consists of the use of several drugs, for example, if the disease is caused by an allergic reaction, then non-steroidal anti-inflammatory drugs and antiallergic drugs are used. Most often, glucocorticoids are used for these purposes.

Severe myocarditis is treated with Prednisolone or Descamethasone. In cases of severe heart failure, hormonal therapy is prescribed. It is also used for autoimmune causes of inflammation of the heart wall and the presence of pericarditis.

The intensity of treatment and dosage of medications is determined purely individually for each patient. In the presence of edema, additional diuretics are given and a fasting fruit-sugar diet is used.

In addition to the above medications, therapy must include vitamins rich in ascorbic acid and potassium. Also, in case of heart pathologies, it is necessary to periodically consume B vitamins.

If there is dizziness, fainting, weakness, lack of appetite and other symptoms, additional medications are prescribed to relieve symptoms that worsen the child’s condition. Heart rhythm disturbances are eliminated with special antiarrhythmic drugs.

In the case of chronic recurrent myocarditis, after hospital treatment, therapy should be continued at home, strictly adhering to medical instructions.

Forecasts

The success of treatment and survival depends on the timely diagnosis of the disease and the underlying cause that provoked the development of inflammation of the heart muscle. Also, the age of the young patient and the presence of concomitant diseases are of no small importance in prognosis.

A high percentage of deaths is observed among newborns and children under three years of age. If such patients survive, sclerotic changes and heart failure of chronic etiology develop in the myocardium. All these pathological changes in the organ end in the early death of the child.

Most often, bacterial myocarditis has a favorable prognosis; it almost always ends in the baby’s recovery. The same cannot be said about viral inflammation of the myocardium.

In children of preschool and school age, treatment of myocarditis ends successfully. The development of heart failure and the formation of sclerotic scar lesions depends on the duration of absence of treatment. The sooner you start therapy, the greater the chance that the disease will not leave complications.

The prognosis of myocarditis worsens in the presence of such consequences as cardiosclerosis, thromboembolism, pericarditis and arrhythmias. In half of all cases, myocardial inflammation has a recurrent course with subsequent development of chronic heart failure.

Diet

Myocarditis is a good reason to provide the child with proper nutrition.

In case of mild inflammation of the heart muscle, the following should be excluded from the diet:

• chocolate;
• fresh baked goods;
• limit pasta consumption;
• reduce the amount of salt you eat;
• monitor your drinking regime.

It is necessary to reduce or completely eliminate fatty, fried and smoked foods. Also, you should not overuse sweets, rich broths and pickles.

A child with chronic myocarditis should be given hard fruits such as plums, grapes, pears and apples in small quantities and infrequently. Or better yet, give them up altogether.

For myocarditis, the following foods should be present in the child’s diet:

• liver (not fried);
• lean meat;
• low-fat fish (pollock, hake, pike perch, etc.);
• eggs (omelet or boiled);
• cereal porridge;
• fresh vegetables;
• boiled carrots and beets;
• greens (parsley, dill, lettuce, etc.).

As a drink, it is allowed to give compote of berries or dried fruits, fresh juices, kefir, and yoghurts. It is necessary to completely stop consuming carbonated drinks, cocoa and coffee drinks.

For sweets, you can give marmalade, marshmallows, homemade jam or honey, the main thing is not to overuse these delicacies.

Prevention

To avoid congenital myocarditis, the expectant mother should carefully plan her pregnancy. It is best to get tested for hidden infections and treat all chronic diseases before conception.

During pregnancy, you should avoid crowded places during the period of colds and flu, and if infection cannot be avoided, treatment should be carried out under the supervision of a doctor.

To prevent acquired myocarditis in the autumn and winter, it is necessary, if possible, to exclude the baby’s contact with sick people. In order to prevent myocardial inflammation due to “childhood” infections, it is necessary to carry out routine vaccination in a timely manner.

Before the onset of seasonal colds, it is important to strengthen the child’s immunity with the help of a vitamin complex and healthy foods. When a cold begins, be sure to visit a pediatrician, and after recovery, undergo the necessary tests to rule out any complications after the illness.

You also need to monitor the child’s daily routine, visit the dentist in a timely manner and not leave diseases such as tonsillitis, sinusitis, gingivitis, etc. untreated.

No matter how hard mothers and fathers try, it is simply impossible to completely protect a child from infectious and viral diseases. But it is quite possible to prevent their complications, and only attentive parents can do this.

To stop the development of myocarditis at the earliest stage of its occurrence, the child should be taken to the doctor at the first changes in behavior and health that appear. These include: fatigue, lethargy, drowsiness, unusual moodiness for the baby, loss of appetite and shortness of breath.

You need to monitor your child especially carefully after suffering an infectious disease, and if there is the slightest suspicion of complications, you must visit the clinic for tests.

If your child has health complaints, you should take him to a pediatrician or family doctor. Only after an initial examination can they suspect the presence of a complication and refer it to the right specialist.

In case of myocarditis, the child needs to be diagnosed by a cardiologist. Depending on the cause of myocardial inflammation, examination by an allergist, rheumatologist, infectious disease specialist or immunologist may be necessary.

Myocarditis in newborns is most often caused by the Coxsackie B (type 1–5) and Coxsackie A13 viruses; it may be a manifestation of an intrauterine generalized inflammatory process with multiple organ damage.

Carditis can develop in the antenatal and postnatal period. In this case, antenatal carditis can be early and late. With early antenatal carditis in the fetus, by the end of intrauterine development the inflammatory process in the heart ends; after birth, the child is usually diagnosed with cardiopathy, with fibrosclerotic processes predominating. Therefore, the so-called early congenital carditis is identified with the concept of fibroelastosis. Fibroelastosis is considered a nonspecific morphological response of the endocardium to any myocardial stress. Such stress can include congenital heart defects, hypoxia, infections, and cardiomyopathies. If a damaging agent (bacteria, viruses) acts on the myocardium in the last 2–3 months of the prenatal period, late antenatal carditis develops (occurs in the last trimester of pregnancy or at the time of birth of the child). Classic inflammation occurs in the myocardium, which corresponds to the term “myocarditis,” and infants are born with an acute phase of inflammation and clinical manifestations of the disease. Acute postnatal carditis develops in children during the neonatal period; it can be congenital or acquired. Late antenatal and acute postnatal carditis is characterized by an increase in heart size and myocardial hypertrophy. All of the listed options for myocardial damage have features determined by etiological factors.

The classification of myocarditis primarily involves dividing them according to etiology. This approach to the classification of myocarditis is implemented in ICD-10. There are no generally accepted pathogenetic principles for the classification of myocarditis. Traditionally, based on pathogenetic characteristics, 3 forms of myocarditis can be distinguished:

• infectious and infectious-toxic – for influenza, enterovirus infection, etc.;
• allergic (immune) - for systemic diseases, infectious-allergic myocarditis, medicinal, serum;
• toxic-allergic – for thyrotoxicosis, uremia.

According to the prevalence of the process, focal myocarditis and diffuse myocarditis are distinguished.

According to the course: acute myocarditis, subacute myocarditis, recurrent myocarditis, chronic myocarditis, abortive myocarditis.

The diagnosis of myocarditis in newborns can be based on the recommendations of the New York Heart Association (NYHA), developed in 1973, 1979, supplemented by M. Take et al. (1981) and Yu. K. Novikov (1988).

To diagnose acute diffuse myocarditis, two groups of diagnostic criteria are used - “major” and “minor” symptoms.

The diagnosis of “myocarditis” is made based on the presence of a chronological connection between signs of a previous infection (allergy, toxic effects, etc.) with two “major” criteria for myocarditis or a combination of one “major” with two “minor” criteria.

"Big" criteria– there is a chronological connection between the infection (or allergic reaction, or toxic effects) and the appearance of the following cardiac symptoms:

• cardiomegaly;
• cardiogenic shock;
• Morgagni–Adams–Stokes syndrome;
• pathological changes on the ECG, including cardiac arrhythmias and conduction disturbances;
• increased activity of cardiac-specific enzymes (CPK, MB-CPK, LDH 1 and LDH 2) and troponin content.

"Small" criteria:

• laboratory confirmation of previous infection (for example, high titers of antiviral antibodies);
• weakening of the first tone;
• protodiastolic gallop rhythm.

Complications of myocarditis:

• acute heart failure (cardiac asthma, pulmonary edema);
• paroxysmal rhythm disturbances with heart failure;
• AV block with cardiac arrest;
• pericarditis;
• development of dilated cardiomyopathy.

Diagnosis of myocarditis

The purpose of diagnosis is to confirm the presence of myocarditis, establish its etiology, the severity of the disease to prescribe the necessary therapy, determine the clinical course of the disease and identify the presence of complications. In clinical practice, complex diagnostic methods are used.

When studying the maternal and obstetric-gynecological history, a connection is established between cardiac symptoms in the newborn and episodes of persistent infectious process in the mother during pregnancy (respiratory viral and bacterial infections, hyperthermia of unknown origin), and a connection between heart damage in the newborn and maternal diseases.

Physical examination findings range from normal to signs of severe cardiac dysfunction. In mild cases, they may appear without signs of intoxication; most often, tachycardia and tachypnea are observed. In more severe forms, signs of left ventricular circulatory failure are observed. With widespread inflammation, classic symptoms of cardiac dysfunction are revealed, such as swelling of the jugular veins, crepitus at the bases of the lungs, ascites, peripheral edema, a third tone or gallop rhythm is heard, which can be observed when both ventricles are involved in the pathological process.

Lashina N. B. Republican Scientific and Practical Center “Mother and Child”.
Published: "Medical Panorama" No. 8, November 2010.

Myocarditis is a congenital or acquired inflammation of the heart muscle (myocardium). The disease can affect the myocardium in children of any age; children aged 4-5 years are most susceptible to it. Girls get sick less often. It is difficult to establish the exact prevalence of myocarditis among children, since in 25-30% of cases the disease is asymptomatic.

The development of myocarditis can be provoked by any infections suffered by the child, in particular, sore throat, scarlet fever, pneumonia, the causative agent of which is often streptococcus.

The causes of myocarditis vary widely:

1. Most often, the provoking factor is infection - myocarditis can occur with any infectious disease.

The causative agents may be:

• bacteria for infections such as: diphtheria, scarlet fever, tuberculosis, tonsillitis, pneumonia, brucellosis, rheumatism, meningococcal infection, etc.;
• viruses – causative agents of diseases such as polio, mononucleosis, chicken pox, measles, etc.;
• fungi (, aspergillus, actinomycetes, etc.);
• spirochetes (Borrelia, Leptospira);
• rickettsia (causing typhus, Q fever);
• protozoa (Toxoplasma, Leishmania, Plasmodium falciparum).

1. Inflammation of the heart muscle can be caused (Trichinella, Echinococcus, Cysticercus, etc.).
2. Myocarditis can develop due to the action of chemical factors or toxic substances:

• snake venom or insect bites;
• inhalation of mercury vapor;
• carbon monoxide poisoning;
• alcohol or drugs (in teenagers).

1. Physical factors can provoke the occurrence of myocarditis: high or low temperature, radiation exposure to the body, etc.
2. Side effects of certain medications: serums, vaccines, some sulfa drugs and antibiotics, etc.
3. Allergic reactions (delayed type) and diseases.
4. Autoimmune diseases in which antibodies are produced that destroy the fibers of the heart muscle.
5. Systemic diseases (rheumatoid arthritis, scleroderma, systemic lupus erythematosus).

The cause of congenital myocarditis in an infant may be an infection suffered by the mother during pregnancy and intrauterine transplacental infection. The most common causative agent of this infection is the Coxsackie virus. In newborns, in this case, manifestations of myocarditis are combined with damage to the liver or brain.

The dependence of the cause of myocarditis on the age of children is also visible. Thus, in young children, the causative agents of the disease are usually viral (more often) or bacterial infections, toxic effects. In adolescents and older children, myocarditis is often of infectious-allergic origin.

Classification

In addition to infectious myocarditis, idiopathic myocarditis occurs. It is diagnosed when the cause of the disease has not been established.

Depending on the course of myocarditis, it can be:

• sharp;
• fulminant (fulminant);
• chronic active;
• chronic persistent (with periodic exacerbations).

According to the prevalence of the process, the disease can be isolated (focal) or diffuse. Based on severity, myocarditis is classified into mild, moderate and severe.

Development mechanism

The stage of viremia or bacteremia (spread of the microorganism through the bloodstream) lasts up to 3 days. With the blood, the pathogen enters the muscle tissue of the heart, attaches to muscle cells, and then penetrates inside the cells. This causes activation of defense mechanisms and an increase in interferon synthesis.

At the same time, anticardiac antibodies are actively produced, which are fixed on myocardial cells and cause necrosis of muscle fibers. At the same time, blood vessels are damaged, which leads to disruption of microcirculation. Exudate sweats through the deformed vascular walls.

With an unfavorable course and chronicity of the process, the following gradually develop:

• cardiomegaly (enlarged heart size);
• sclerotic changes in the myocardium;
• progresses ;
• occurs (increase in the volume of the heart cavities).

Isolated myocardial damage develops in rare cases. More often, inflammation also affects the outer (pericardium) or inner (endocardium) lining of the heart. Such widespread inflammation develops in 30% of cases. Simultaneous inflammation of all the membranes of the heart is called “pancarditis”.

Symptoms

Clinical manifestations of myocarditis depend on its cause, the age of the child, the nature of the course, the prevalence and depth of myocardial damage. Symptoms of heart damage may occur several days after the initial infection or several weeks later.

A feature of the clinical manifestations of myocarditis in children is the acute onset, severity and rapid increase in symptoms.

Congenital myocarditis manifests itself in the first weeks after birth and is severe.

Its symptoms are:

• pallor and grayish tint of the skin;
• weakness (the baby gets tired even when feeding);
• increased heart rate and breathing (shortness of breath) appear first with the slightest exertion (during bathing, feeding, changing clothes, defecation), and over time at rest;
• restlessness and poor sleep;
• swelling may occur;
• the appearance and progression of heart failure.

A doctor, examining a child, may detect an expansion of the borders of the heart and an enlarged liver. The amount of urine excreted per day decreases.

In infants, myocardial inflammation can occur both during infection and several days after it. The initial symptom may be shortness of breath or a rise in temperature to 37.5 ° C (but fever with higher values ​​is also possible).

Characteristic symptoms are also:

• pallor;
• increased heart rate;
• weakness;
• weight loss;
• breast refusal.

In some children, the disease may begin with collapse: loss of consciousness for a short time, the body becomes covered in cold sweat, and convulsions are possible.

In preschool age children, the disease may begin with abdominal pain and possibly loose stools.

Symptoms of the disease may also include:

• lethargy;
• dry cough;
• shortness of breath, first with exertion, and then at rest (respiratory rate can reach 60-100 in 1 minute);
• groaning breath;
• heartache;
• liver enlargement;
• pallor, acrocyanosis (blueness of the lips and nail phalanges of the fingers);
• limbs cold to the touch;
• fainting and dizziness;
• frequent headaches;
• poor sleep;
• developmental delay;
• rapid fatigue after light exertion.

Due to severe shortness of breath, children take a forced position - reclining or sitting. And although an increase in the boundaries of the heart and an increase in heart rate are less common, different types of rhythm disturbances (arrhythmias) may occur. In severe cases, pulmonary edema is possible with an unfavorable outcome.

At older ages, the course of the disease is more benign. It manifests itself after an infection, usually at intervals of 2-3 weeks with the following symptoms: weakness, fatigue, severe pallor. Abdominal pain, joint or muscle pain are noted. The temperature rises slightly or remains normal.

Idiopathic myocarditis has a severe course. The focal process often manifests itself as arrhythmias due to damage to the conduction system. With diffuse inflammation of the heart muscle, the contractile function of the myocardium suffers more, which causes heart failure with stagnation in the systemic or pulmonary circulation.

Diagnostics

Many methods are used to diagnose myocarditis:

1. When interviewing parents or the child himself, the doctor details the complaints, receives information about the illness suffered the day before, the dynamics of the development of the pathology, and other data.
2. Examining the patient, the doctor identifies pallor and acrocyanosis, fever, determines the pulse and respiratory rate, the boundaries of the heart, blood pressure, liver size, edema, and listens to the heart and lungs.
3. Blood test:

• clinical – signs of inflammation (increased leukocytes and accelerated ESR) or an allergic reaction (increased eosinophils) may be detected;
• biochemical study to determine the activity of myocardial enzymes, C-reactive protein, and other indicators;
• serological analysis to detect specific antibodies and confirm the viral nature of a previous infection.

1. An ECG reveals conduction disturbances, arrhythmias, and metabolic changes in the myocardium. Sometimes 24-hour Holter monitoring is used (ECG recording continuously throughout the day with a special device).
2. Echocardiography (ultrasound of the heart) detects structural changes in the heart (dilation of the cavity, defects), the presence of fluid in the heart sac, blood flow speed and other functional indicators.
3. Chest X-ray reveals an enlarged heart and signs of congestion in the lung tissue.
4. In diagnostically difficult and severe cases, endomyocardial biopsy may be prescribed - an invasive diagnostic method to determine the nature and extent of the process.

Treatment

Children with acute myocarditis are treated in a hospital. It is mandatory for the child to remain in bed for about 2 weeks (the duration is determined individually).

No specific therapy has been developed for myocarditis. The main task is to treat the underlying disease that caused myocarditis. In addition, symptomatic therapy is prescribed.

Components of complex treatment are:

• oxygen therapy for severe disease;
• antibiotics for a previous bacterial infection (Oxacillin, Penicillin, Augmentin, Ospamox, Minocycline, Doxycycline, etc.);
• antiviral agents in case of viral infections (Interferon, Ribavirin, Immunoglobulin); with intravenous administration of gammaglobulin, the functional recovery of the myocardium increases and the prognosis for patients is more favorable;
• non-steroidal anti-inflammatory drugs (Voltaren, Ibuprofen, Butadione, Brufen, Indomethacin, etc.);
• corticosteroid hormones (in severe cases): Prednisolone, Dexamethasone, Hydrocortisone, Triamcinolone;
• for heart failure, digitalis preparations are prescribed after the inflammation in the heart muscle has stopped;
• for edema, diuretics are prescribed (Lasix, Hypothiazide, Furosemide, Novurit, Trifas);
• vitamin therapy (from group B, vitamin C);
• for persistent pain, minimal doses of Anaprilin are used;
• If the rhythm is disturbed, the cardiologist will select antiarrhythmic drugs.

In case of persistent arrhythmia and ineffectiveness of medications, radical surgical treatment is possible - a pacemaker is implanted or transvenous cardiac pacing is performed.

In case of chronic myocarditis with relapses, it is advisable to continue treatment in a sanatorium after hospitalization.

Diet therapy

In case of myocarditis, it is necessary to pay attention to the child’s nutrition. It is better to cook dishes by steaming. Small portions should be given to the child 5-6 rubles. in a day.

The following products are allowed:

• meat (beef, chicken);
• fish (low-fat varieties);
• (any);
• fermented milk products (yogurt, kefir, cottage cheese, fermented baked milk, sour cream);
• vegetables (stewed, boiled): cauliflower, lettuce, beets, parsley;
• in the form of an omelet (3 pieces per week).
• and fresh fruit of soft varieties (excluding plums, grapes, quinces, hard pears and apples).

Children with a sweet tooth are allowed jam (if there is no allergy), marmalade, and marshmallows.

You should limit your consumption of chocolate, baked goods, pastries, pancakes, and pasta.

The following are subject to exception:

• spicy and fried foods;
• fatty meat (pork, goose, lamb, duck) or fish;
• rich broths;
• pickles;
• smoked meats;
• seasonings;
• carbonated drinks.

If you have edema, you should limit your intake (no more than 6 g/day), as it will retain water in the body and increase the load on the heart.

When treating with corticosteroid drugs and diuretics, it is necessary to consume foods containing potassium (raisins, carrots, dried apricots, etc.).

Forecast

The outcome options for myocarditis depend on the nature and extent of the inflammatory process in the heart muscle, the age of the child and the state of the immune system.

The outcome of the disease can be:

• sudden death;
• dilated cardiomyopathy;
• heart failure;
• cardiosclerosis;
• thromboembolism;
• arrhythmias;
• recovery.

The prognosis of myocarditis in young children and newborns is especially serious - among them the mortality rate remains high. Bacterial myocarditis often has a favorable outcome, while viral myocarditis usually ends in death.

In older children, with timely diagnosis and proper treatment, a favorable outcome is possible. With mild severity, children more often recover without impairment of heart function.

Dispensary observation

A child with myocarditis is subject to observation by a pediatric cardiologist (or pediatrician) for at least 5 years. After a treatment course in a hospital, a medical examination is carried out monthly (4 months), then once a quarter for a year, then twice a year. Monitoring ECGs are performed at every visit to the doctor, and echocardiography is performed annually. It is necessary to exclude hypothermia in children and significant physical activity (the child is transferred to a special physical education group).

Prevention

Preventive measures are aimed at eliminating factors that can cause myocarditis in children.

These include:

• examining a woman before a planned pregnancy and excluding infections during pregnancy;
• maximum exclusion of contacts of children with infectious patients;
• timely (according to the calendar) professional vaccinations for the child;
• flu vaccination when there is a threat of an epidemic;
• treatment of existing foci of infection.

Summary for parents

Myocarditis is severe in young children and can leave behind serious cardiac dysfunction. That is why parents should take a serious approach to the treatment of viral respiratory diseases, sore throat, pneumonia, which children are so often susceptible to and which can cause myocarditis in a child.