Heart Inflammation

Endocarditis is inflammation of the inner lining of the heart chambers and valves, or endocardium. Endocarditis is a rare but life-threatening disease. In endocarditis, clumps of bacteria or fungi, along with blood cells, collect on the endocardium. These clumps occur more often on the heart valves than on the heart chambers. Pieces of these clumps can break off and travel to different parts of the body, blocking blood flow or spreading infection.

Myocarditis is an uncommon disease marked by inflammation of the heart muscle, called the myocardium, and other changes to the heart muscle cells that may be acute or chronic. Myocarditis can affect small or large sections of the heart muscle, making it harder for the heart to pump blood, which in turn can lead to heart failure.

Pericarditis is a condition in which the pericardium—the sac surrounding the heart—gets inflamed. This sac is made of two thin layers of tissue with a small amount of fluid in between. The fluid keeps the layers from rubbing against each other and causing friction. The pericardium holds the heart in its position in the chest and protects it from infection.

Depending on how long you have had it, your doctor may categorize pericarditis as acute, subacute, chronic, or recurrent, the latter meaning it is a repeat event.

Viral, bacterial, and fungal infections can cause heart inflammation.

• Viral infections are the most common cause of myocarditis and pericarditis. These may include adenovirus, coxsackievirus, herpes virus, influenza (flu) virus, and parvovirus B19. Viruses may infect the heart muscle tissue, causing acute or chronic immune responses from the body.
• Bacteria are the most common cause of endocarditis, which occurs when bacteria and blood cells form clumps, typically on the heart valves. In most developed countries Staphylococcus aureus is the most common type of bacteria that causes endocarditis. Bacteria can enter the blood during invasive medical procedures or intravenous drug use. Streptococcus bacteria can also cause endocarditis, but this is more common in less developed countries. Pericarditis caused by bacteria is rare in the United States and other developed countries. However, in developing countries, 70 percent of pericarditis cases are caused by Mycobacterium tuberculosis, the organism that causes tuberculosis.
• Fungi are rare causes of myocarditis and pericarditis. Most commonly, fungal endocarditis is caused by either Candida or Aspergillus. These infections are more common in immunosuppressed patients, including those who have HIV.
• Other infections. Another infectious cause of myocarditis includes the parasite that causes Chagas disease, which is a serious health problem in Latin America. The parasite can specifically affect the heart at the time of infection and may lead to the need for a pacemaker.

How do viruses cause myocarditis?

Autoimmune diseases such as rheumatoid arthritis and lupus erythematosus may cause pericarditis or myocarditis. They can also damage the heart valves, which can lead to endocarditis.

Medicines can cause side effects that may lead to myocarditis, pericarditis, or both. These medicines include:

• Antibiotics, such as penicillin
• Antidepressants, such as tricyclic antidepressants
• Benzodiazepines, known as tranquilizers, such as lorazepam and diazepam
• Diuretics, which are medicines, such as furosemide and hydrochlorothiazide, that help your body get rid of fluid
• Heart medicines, such as amiodarone, hydralazine, methyldopa, and procainamide
• Psychiatric medicines, such as clozapine and lithium
• Seizure medicines, such as phenytoin
• Vaccines, which may cause allergic reactions leading to myocarditis, although this is rare
• Weight-loss medicines, such as phentermine-fenfluramine or phen-fen

Environmental factors that may cause myocarditis include:

• Heavy metals, such as copper and lead
• Radiation

• Treatment will discuss the medicines or procedures that your doctors may recommend if you are diagnosed with heart inflammation—endocarditis, myocarditis, or pericarditis.

Different age groups are at risk for different types of heart inflammation:

• Although they can affect all ages, myocarditis and pericarditis occur more often in young adults. Pericarditis also commonly affects middle-aged adults.
• Older adults are more at risk for endocarditis caused by bacteria. In recent years, age-related heart valve infections have been on the rise.

Heart inflammation from endocarditis, myocarditis, and pericarditis is more common in men than in women, except when caused by autoimmune diseases, such as lupus and rheumatoid arthritis, which are more common in women.

Endocarditis and pericarditis occur twice as often in men as in women.

Genetics play a role in the risk of developing all three types of heart inflammation. Your genes may be partly responsible for how your body responds to infection and inflammation and whether you develop myocarditis or pericarditis.

People who have structural or congenital heart defects, such as problems with the heart valves, may be at higher risk for infection that can cause endocarditis.

Certain inherited conditions can affect your risk for heart inflammation. For example, you may be at higher risk for myocarditis and pericarditis if you have familial Mediterranean fever or tumor necrosis factor receptor-associated periodic syndrome (TRAPS). These rare conditions affect how the body controls inflammation.

Chagas disease, common in Latin America, can cause acute and chronic myocarditis. It is caused by a parasite that is spread by certain types of insects. Endocarditis caused by Streptococcus bacteria is more common in less developed countries.

Certain lifestyle choices raise your risk for endocarditis or myocarditis. These include:

• Drinking too much alcohol, which may cause inflammation of the myocardium and could lead to reduced heart function and heart failure
• Drug use such as cocaine and amphetamines and intravenous drug use with endocarditis
• Poor dental health, which increases the risk for bacterial endocarditis

Some medical conditions can increase your risk of endocarditis, myocarditis, or pericarditis. These include:

• Cancers, such as advanced lung and breast cancer or lymphoma. Medicines used to treat these types of cancer can cause myocarditis or pericarditis.
• Diabetes, which can make you more likely to develop infections
• Eating disorders such as anorexia
• End-stage kidney disease, which can result from the buildup of waste products in the blood
• HIV/AIDS, which may lead to myocarditis from a number of causes, including viral, bacterial, or fungal infection; treatment; and nutritional deficiencies. People who have HIV/AIDS may be at higher risk for fungal infection.
• Skin disorders, such as burns or recurrent infections
• Trauma or injury to the chest or esophagus, or indirect injury to the chest wall

Certain medical procedures can increase your risk of endocarditis, myocarditis, or pericarditis, including:

• Central venous line, which is an intravenous catheter that goes into a larger central vein in your body
• Devices in the heart, such as artificial heart valves, pacemakers, and implantable cardioverter defibrillators
• Hemodialysis for end-stage kidney disease. Infection may result from access to blood vessels needed for hemodialysis.
• Medical procedures, such as having a central venous line, which is an intravenous catheter that goes into a larger central vein in your body; heart ablation for abnormal heart rhythm; or treatments for coronary heart disease
• Radiation therapy to treat cancers such as lung and breast cancer and lymphoma. This may cause myocarditis or pericarditis.
• Treatments for ischemic heart disease

Your doctor may recommend steps to prevent bacterial growth on the endocardium in people who have risk factors for endocarditis. These steps may decrease your risk of endocarditis.

• Avoid using illegal intravenous (IV) drugs.
• Practice careful skin hygiene, such as regularly washing your skin and immediately washing any cuts or scrapes to prevent infection.
• Practice good dental hygiene, including daily brushing and flossing and regular visits to the dentist.
• Take antibiotics before some medical procedures, but only as directed by your doctor.

Many causes of myocarditis and pericarditis are difficult or impossible to avoid or prevent. Controlling risk factors for diseases such as HIV and avoiding substances such as amphetamines and cocaine may decrease your risk for myocarditis.

• Diagnosis will explain tests and procedures that your doctor may use to diagnose types of heart inflammation.
• Living With will discuss what your doctor may recommend to prevent your endocarditis, myocarditis, or pericarditis from recurring, getting worse, or causing complications.
• Research for Your Health will explain how we are using current research and advancing research to prevent endocarditis, myocarditis, and pericarditis.

If a virus causes your heart inflammation, you may have a cough, runny nose, or gastrointestinal symptoms a few weeks before symptoms of your heart inflammation. The signs and symptoms of heart inflammation are different depending on the type of heart inflammation you have.

Endocarditis

• Fever and chills
• New or worsening heart murmur
• Blood in urine
• Spleen that is larger than normal
• Abdominal pain
• Chest pain
• Cough, with or without the presence of blood
• Loss of appetite and weight loss
• Muscle, joint, and back pain
• Night sweats
• Pain where an infected cardiac device is located
• Shortness of breath
• Skin changes, which can occur with endocarditis. These may be painful red or purple bumps, or painless flat red spots on places such as the palms of your hands or soles of your feet, or tiny reddish purple spots from broken blood vessels.

Myocarditis

• Chest pain and discomfort
• Heart palpitations
• Fainting
• Shortness of breath
• Fatigue
• Abdominal pain
• Exercise intolerance, or no longer being able to exercise
• Fever
• Loss of appetite
• Swelling of feet or legs
• Weakness

Pericarditis

• Chest pain. Chest pain from pericarditis typically feels sharp, gets worse with breathing, and feels better with sitting up and leaning forward.
• Fast heartbeat
• Fever
• Shortness of breath

Complications of heart inflammation vary depending on the type of heart inflammation. Some complications can be life-threatening.

Endocarditis

• An embolus. In endocarditis, a clump of bacteria or fungi, along with blood cells, forms on the damaged heart valves. A piece of this clump can break off, forming a type of embolus that travels through the blood to different parts of the body, blocking blood flow and spreading infection. An embolus that travels to the brain can cause stroke, meningitis, or an infection called a brain abscess. An embolus that travels to the lung can cause lung damage or a lung abscess. An embolus may also travel to the kidney or spleen, blocking blood flow to those organs.
• Arrhythmia or heart conduction disorders
• Heart failure
• Sepsis, a life-threatening blood infection

Myocarditis

• Arrhythmia or heart conduction disorders
• Cardiomyopathy
• Heart failure and cardiogenic shock
• Lung complications, such as fluid in the lungs or effusions between the layers covering the lungs that may occur with heart failure
• Syncope

Pericarditis

• Pericardial effusion, in which fluid collects in the sac around the heart
• Cardiac tamponade, in which too much fluid collects in the pericardium, or the sac around the heart. This complication of pericarditis prevents the heart from properly filling with blood, causing a sharp drop in blood pressure that can lead to decreased blood flow to your body.
• Constrictive pericarditis, in which scar-like tissue forms through the pericardium. The sac becomes stiff and cannot move properly. The scarred tissue prevents the heart from filling with blood properly.

• Diagnosis will discuss tests and procedures used to diagnose the different types of heart inflammation.
• Treatment will discuss treatments and some possible complications and side effects of these treatments.

Because the signs and symptoms of heart inflammation vary among the three types and from one person to the next, it is sometimes difficult to diagnose endocarditis, pericarditis, or myocarditis. To help, your doctor may ask questions such as these:

• Have you had endocarditis, myocarditis, or pericarditis in the past?
• Have you had a recent illness or injury to the chest?
• Have you had any symptoms, such as fever, chest pain, or shortness of breath?
• Have you any other medical conditions or any other risk factors for heart inflammation, including exposure to certain medicines or toxins or a travel history that may be significant?

During the physical exam, your doctor may take these steps:

• Check your legs for swelling, a sign of heart failure
• Check your skin for any changes, as may be seen in cases of endocarditis
• Check your temperature to determine if you have a fever
• Feel your stomach, particularly for a spleen that is larger than normal, or to determine if you have abdominal pain, which may occur with endocarditis
• Listen to your heart for a new murmur that may be heard with endocarditis, a pericardial rub that may be heard with pericarditis, or an abnormal heart rhythm
• Listen to your lungs

Your doctor may recommend other tests and procedures to diagnose the different types of heart inflammation, including:

• Echocardiography (echo) to look for heart valve problems, problems in the structure or function of the heart, or a thickening of the pericardium
• Electrocardiogram (ECG or EKG) to look for changes in your heart’s electrical activity, which do not necessarily indicate myocarditis, endocarditis, or pericarditis. It may help distinguish a heart attack from pericarditis.
• Cardiac magnetic resonance imaging (MRI) to detect inflammation and swelling of the myocardium and pericardium. Your doctor may also use MRI to look for complications of endocarditis in other parts of the body, such as the brain, which may indicate stroke.
• Cardiac computed tomography (CT) to help diagnose pericarditis, as well as the complications of endocarditis and pericarditis
• Endomyocardial biopsy (EMB) to test very small pieces of the heart to look for myocarditis
• Heart valve tissue testing to identify the microbes from the heart valve or its vegetation that may be causing your endocarditis
• Pericardiocentesis to remove excess fluid in the pericardium, called a pericardial effusion. Your doctor will insert a needle or tube, called a catheter, into the chest wall to remove this excess fluid. Your doctor will look at the fluid for bacteria, signs of cancer, or other causes of pericarditis.
• Positron emission tomography (PET) scan or nuclear medicine scan to diagnose endocarditis, myocarditis, or pericarditis. In both types of imaging studies, a small amount of a radioactive substance is given to see where the body takes it up. This may indicate infection, cancer, or other conditions in the places where it shows up on imaging.

Blood tests may help your doctor find the cause of your heart inflammation and may include:

• Blood cultures to identify and treat the exact bacterium, virus, or fungus that is causing the infection in endocarditis or pericarditis
• Cardiac troponins or creatine kinase-MB, which are blood markers that increase when there is damage to your heart. Since there are no specific blood tests for myocarditis, these markers are useful to show injury to the heart muscle. However, they are also increased with heart attack or heart failure and do not necessarily mean you have myocarditis. They are often normal in cases of subacute or chronic myocarditis.
• C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), which may indicate inflammation in the body if higher than normal
• Complete blood count to look for higher levels of white blood cells, which might indicate infection
• Serum cardiac autoantibodies (AAbs), which are antibodies that your body may start to make if you have myocarditis. These antibodies recognize your own heart muscle.
• Testing for specific organisms, such as Borrelia burgdorferi, which causes Lyme disease; Mycobacterium tuberculosis, which causes tuberculosis; HIV; or hepatitis C

Your doctor may order additional tests to find out whether another condition may be causing your symptoms.

• Blood markers of autoimmune disease, such as anti-nuclear antibodies (ANAs) and anti-neutrophil cytoplasm antibodies (ANCAs), may be tested if your doctor suspects an autoimmune cause.
• Coronary angiogram may be performed if you have symptoms similar to those of a heart attack, such as chest pain or pressure. This test will tell the doctor whether your symptoms are from ischemic heart disease.

• Return to Risk Factors to review genetic factors, lifestyle choices, or medical conditions that increase your risk of developing heart inflammation.
• Return to Signs, Symptoms, and Complications to review common signs and symptoms of endocarditis, myocarditis, or pericarditis.
• Return to Screening and Prevention to review how to screen for heart inflammation.

Your doctor may prescribe one or more medicines to treat heart inflammation, depending on the type and cause of heart inflammation.

Endocarditis

• Antibiotics to treat bacterial infections. Side effects of antibiotics depend on which antibiotic is used but may include diarrhea; problems with hearing, balance, and kidneys; and decreased white blood cell counts. Some of these side effects may not happen until treatment is finished.
• Antifungal medicines to treat fungal infections. Sometimes your doctor may recommend lifelong oral antifungal treatment to prevent the infection from returning. Possible side effects of antifungal medicines include allergic reactions, such as diarrhea, dizziness, itching, blisters or hives, difficulty breathing, weight loss, and jaundice.
• Blood thinners to treat some types of endocarditis

Myocarditis

• Corticosteroids to lower the activity of the body’s immune system. Corticosteroids may be used to treat myocarditis caused by autoimmune diseases, such as lupus.
• Heart failure medicines to decrease the work of the heart when heart failure is a complication. Your doctor may recommend medicines such as beta blockers and angiotensin-converting enzyme (ACE) inhibitors.
• Intravenous immunoglobulin (IVIG) helps control the body’s immune and inflammatory response.

Pericarditis

• Anti-inflammatory medicines to treat pericarditis. These include colchicine, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and indomethacin. Side effects are mainly gastrointestinal and include abdominal pain, nausea, vomiting, and diarrhea.
• Corticosteroids to lower the activity of the body’s immune system. With pericarditis, corticosteroids are used only in patients who are not responding to or cannot take NSAIDs.
• Intravenous immunoglobulin (IVIG) to help control the body’s immune and inflammatory response. This may be used when there is an autoimmune disorder, such as lupus.

Your doctor may consider procedures and surgeries to treat your heart inflammation, including:

• Heart surgery to manage damage to valves or nearby heart tissue from endocarditis. It may involve removal of infected tissues or reconstruction of the heart, including repairing or replacing the affected valve.
• Pericardiocentesis to remove excess fluid in the pericardium, called a pericardial effusion

Your doctor may recommend lifestyle changes depending on the cause of your heart inflammation. These recommendations may include:

• Avoiding amphetamines, cocaine, or IV drugs
• Maintaining good dental hygiene

• Living With will discuss what your doctor may recommend, including lifelong lifestyle changes, medical care, and procedures to help prevent your heart inflammation from recurring, getting worse, or causing complications.
• Research for Your Health will discuss how we are using current research and advancing research to treat people with endocarditis, pericarditis, and myocarditis.

Follow up with your doctors as instructed. Your exact follow-up will depend on the cause and severity of your disease. Ongoing medical care may include:

• Continuing all treatments as directed by your doctor
• Getting regular check-ups and follow-up tests with your doctor
• Getting regular dental visits

Return to Treatment to review possible treatments for endocarditis, myocarditis, and pericarditis.

Your doctor may recommend the following to monitor your condition and the effectiveness of the treatments:

• Blood tests for detecting the bacteria causing endocarditis may be performed every 24 to 48 hours until the infection is gone from the bloodstream. For pericarditis, blood tests that look for increased levels of inflammation—C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)—may be repeated periodically until the levels return to normal. Your doctor may also continue anti-inflammatory treatment until these levels return to normal.
• Cardiac MRI may be repeated to monitor myocarditis.
• Echocardiography (echo) allows doctors to look at your heart after treatment and have images to use for comparison when monitoring for any changes. This test may be repeated periodically to monitor your heart function.

Make sure you are familiar with the signs and symptoms of your condition, such as chest pain, cough, fever, and shortness of breath. Call your doctor with any new symptoms.

Repeat events of heart inflammation can happen. People with endocarditis have a lifelong risk. Repeat events of pericarditis are common in the first 18 months after treatment. People with myocarditis are at risk for a repeat event for years after the first occurrence.

To prevent complications, it is important to take these steps:

• Continue all medicines as directed by your doctor, including those for complications such as heart failure or arrhythmias or for medical conditions that may have contributed to your endocarditis, myocarditis, or pericarditis. Treatment for endocarditis and pericarditis often lasts weeks. You may need to take some medicines throughout your lifetime. If prescribed, lifelong use of antifungals for fungal endocarditis or colchicine for pericarditis may lower your risk of a repeat event.
• Do not exercise until given permission by your doctor. For myocarditis, this may be several months or longer after treatment.
• When possible, avoid known causes and risk factors.

Serious complications can include repeat events and new or worsening heart failure. Tell your doctor if you experience fever or chills, or symptoms of heart failure, such as shortness of breath, fatigue, or swelling in your legs.

Review the symptoms and complications of the different types of heart inflammation from endocarditis, myocarditis, and pericarditis.

Depending on the cause and amount of heart inflammation, you may need treatments to manage complications.

• Anti-inflammatory medicines to decrease the chance of recurrent pericarditis. These include colchicine, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and indomethacin.
• Implantable cardioverter defibrillator or pacemaker to control irregular heartbeats. Placement of these devices should wait until after the acute episode of myocarditis, because the heart may heal completely.
• Pericardiectomy, or the surgical removal of the pericardium. It is a final but potentially successful option for people who have certain types of pericarditis, such as recurrent pericarditis that does not respond to treatment or constrictive pericarditis that is end-stage.