Causes of Myocarditis Infectious Etiologies: • Viral agents: Adenoviruses, Enteroviruses (coxsackievirus), Herpesviruses (human

Causes of Myocarditis 1. Infectious Myocarditis • Bacterial - Staphylococcus, Streptococcus, Pneumococcus, Meningococcus, Gonococcus, Salmonella, Corynebacterium diphtheriae, Haemophilus influenzae, Myobacterium (tuberculosis), Mycoplasma pneumoniae, Brucella • Spirochaetal - Borrelia (Lyme disease), Leptospira (Weil disease) • Fungal - Aspergillus, Actinomyces, Blastomyces, Candida, Coccidioides, Cryptococcus, Histoplasma, Mucormycoses, Nocardia, Sporothrix • Protozoal - Trypanosoma cruzi, Toxoplasma gondii, Entamoeba, Leishmania • Parasitic - Trichinella spiralis, Echinococcus granulosus, Taenia solium • Rickettsial - Coxiella bumetti (Q fever), R. rickettsia (Rocky Mountain Spotted fever), R. tsutsugamuschi • Viral - RNA viruses: Cox sackie viruses A and B, echo viruses, polio viruses, influenza A and B viruses, respiratory syncytial virus, mumps virus, measles virus, rubella virus, hepatitis C virus, dengue virus, yellow fever virus, Chikungunya virus, Junin virus, Lassa fever virus, rabies virus, human immunodeficiency virus-1 DNA viruses: Adenoviruses, parvovirus B 19, cytomegalovirus, human herpes virus-6, Epstein-Barr virus, varicella-zoster virus, herpes simplex virus, variola virus, vaccinia virus 2. Immune-mediated myocarditis • Allergens - Tetanus toxoid, vaccines, serum sickness. Drugs: Penicillin, cefaclor, colchicine, furosemide, isoniazid, lidocaine, tetracycline, sulfonamides, phenytoin, phenylbutazone, methyldopa, thiazide diuretics, amitriptyline • Alloantigens - Heart transplant rejection • Autoantigens - Infection-negative lymphocytic, infection-negative giant cell. Associated with autoimmune or immune-oriented disorders: Systemic lupus erythematosus, rheumatoid arthritis, Churg-Strauss syndrome, Kawasaki's disease, inflammatory bowel disease, scleroderma, polymyositis, myasthenia gravis, insulin-dependent diabetes mellitus, thyrotoxicosis, sarcoidosis, Wegener's granulomatosis, rheumatic heart disease (rheumatic fever) 3. Toxic myocarditis • Drugs - Amphetamines, anthracyclines, cocaine, cyclophosphamide, ethanol, fluorouracil, lithium, catecholamines, hemetine, interleukin-2, trastuzumab, clozapine • Heavy metals - Copper, iron, lead (rare, more commonly cause intramyocyte accumulation) • Miscellaneous - Scorpion sting, snake and spider bites, bee and wasp stings, carbon monoxide, inhalants, phosphorus, arsenic, sodium azide • Hormones - Phaeochromocytoma, vitamins: beri-beri • Physical agents - Radiation, Electric Shock #Myocarditis #Causes #differential #diagnosis #cardiology

Causes of Acute Pericarditis: Infectious; Viral: Adenovirus Coxsackie virus A and B Echovirus Epstein-Barr virus Hepatitis Human immunodeficiency virus Influenza Mumps Bacterial: Menangococcus Neisseria Salmonella Staphylococcus Streptococcus Streptococcus pneurnoniae (in children) Syphilis Tuberculosis Whipple disease Fungal: Aspergillosis Blastomycosis Candida Coccidioidomycosis Histoplasmosis Other: parasitic Protozoal Noninfectious Acute idiopathic* Acute myocardial infarction* Neoplastic* Primary tumors: Fibroma Lipoma Mesothelioma Sarcoma Metastatic tumors: Breast Leukemia Lung Lymphoma Melanoma Sarcoma Trauma: Direct pericardial injury Cardiac injury (e.g., cardiac surgery, catheterization) Pericardial perforation (e.g., gastric/ esophageal perforation. chest trauma) Indirect pericardial injury Blunt chest trauma Radiation Aortic dissection (with leakage into pericardial sac) Chylopericardium Familial pericarditis Pregnancy Hypersensitivity- or autoimmunity- related Medication induced (select drugs): Anticoagulants Hydralazine Isoniazid Minoxidil Phenytoin (Dilantin) Procainamide Metabolic disorders: Renal Insufficiency (i.e.. dialysis pericarditis) Uremia Postcardiac injury: Postmyocardial infarction (Dressler syndrome) Postpericardiotomy syndrorne Posttraumatic Collagen vascular disease: Ankylosing spondylitis Der matomyositis Familial Mediterranean fever Polyarteritis nodosa Rheumatoid arthritis Sarcoidosis Scleroderma Sjögren syndrome Systemic lupus erythematosus Wegener granulomatosis Rheumatic fever #Causes #Pericarditis #Differential #Diagnosis

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Transverse Myelitis Overview Focal inflammatory disorder of the spinal cord resulting in rapid onset of weakness, sensory alterations, and bowel or bladder dysfunction Epidemiology: • 1400 new cases in the US each year • Bimodal peaks between the ages of 10 to 19 years and 30 to 39 years • 10-33% develop MS over a five to ten-year period • 75-90% of cases TM is monophasic Pathophysiology of Transverse Myelitis: • Excessive activation of an immune response against the spinal cord that results in CNS inflammation and tissue damage Mechanisms: • Idiopathic: etiology unknown • Infectious: Direct microbial infection versus molecular mimicry or super-antigen mediated disease • Immune Mediated Transverse Myelitis - Clinical Presentation: Injury to the spinal cord (Myelopathy) without cord compression (MRI) and findings of varying degrees of: 1. Weakness: - Weakness that preferentially affects the flexors of the legs and the extensors of the arms (pyramidal distribution of weakness) - Flaccidity -> Spasticity - Reflexes: decreased or absent initially -> Hyperreflexia develops later 2. Sensory Alterations: - Sensory features: paresthesias ascending from feet with or without back pain at/near level of myelitis 3. Autonomic Dysfunction: - Autonomic: Bowel/Bladder dysfunction, temperature dysregulation, bouts of HTN Diagnostic Criteria: • Sensory, motor, or autonomic dysfunction located at the spinal cord • T2 hyperintense signal change on spinal MRI • No evidence of compressive cord lesion • Bilateral signs and/or symptoms • Clearly defined sensory level • CSF inflammation: CSF pleocytosis, elevated IgG index • Progression hours to days Transverse Myelitis Diagnosis: • Must rule out compressive myelopathies! • Gadolinium-enhanced MRI of the spinal cord - Increased T2 signal and expansion of the cord - No cord compression - More than 2/3 of the cross-sectional area is involved - Focal enlargement - T2WI hyperintensity - Enhancement - TM and tumor the cord is swollen, while in MS and ADEM the cord is not swollen or less swollen - Lesion > 3 levels: Evaluate for NMO, SLE or Sjogren's • CSF: - Abnormal in 50% of cases - Pleocytosis: Mild lymphocytic - Pleocytosis > 100 cells: consider infectious myelitis - Elevated IgG index - Oligoclonal IgG bands (85 to 95% Predictive of MS) • Check Vitamin B12 and copper levels • NMO-IgG (anti-AQP4) should be tested and if negative, MOG-IgG test should be ordered • Infectious causes need to be ruled out • Brain MRI: Check for brain and/or optic nerve lesions suggestive of multiple sclerosis, NMOSD, MOG antibody disorders, or ADEM Transverse Myelitis Etiologies: • Demyelination: - Multiple sclerosis (MS) - Neuromyelitis optica (NMO) - Idiopathic transverse myelitis - ADEM - Post vaccination - Myelin oligodendrocyte glycoprotein (MOG) antibody disorders • Infections: - Herpes zoster, West Nile virus - Herpes simplex virus, HIV, Hep A/B/CMV, TB - Treponema Pallidum - Lyme Disease Mycoplasma - Leptospirosis, Brucellosis - Dengue, EBV, Influenza, Enteroviruses • Idiopathic: - Post Infectious - Post Vaccine • Inflammatory Disorders: - SLE - Neurosarcoidosis - MCTD - Bechet disease - Sjogren - Vasculitis- Heroin • Paraneoplastic: - AntiGAD65, NMDAR, AntiCRMP IgG, Anti-Hu - Antiamphiphysin antibodies • Nutritional Deficiency: - Vitamin B12, E, D, copper Transverse Myelitis Treatment: • Steroids • Plasma exchange • Immunomodulatory agents: IVIG • Cyclophosphamide #Transverse #Myelitis #diagnosis #management #neurology #differential