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The organisms reported to cause myocarditis and pericarditis in England and Wales
Journal of Infection (1996) 32, 223-225
The Organisms Reported to Cause Infective Myocarditis and Pericarditis in England and Wales C. K. Fairley*, IVI. Ryan, P. G. Wall and J. Weinberg Public Health Laboratory Service, Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, U.K. Accepted for publication 13 January 1 9 9 6
It is difficult to acquire an overall perspective of the range of organisms responsible for infective myocarditis or periearditis, and their relative importance, as most studies have involved only case reports or case series of a single oNanism. This stu@ analyses reports to the Communicable Disease Surveillance Centre, of the Public Health Laboratory Service. Reports where myocarditis or pericarditis was included as the main clinical features between 1990 and 1993 were studied. Between 1990 and 1993, 368 cases of myoearditis and/or pericarditis were reported to CDSC. Viruses were reported to cause 253 (69%) eases, bacteria were responsible for 49 (13%) cases, mycoplasma for 32 (9%) cases, chlamydia for 16 (4%) cases and Mycobacterium tuberculosis for nine (2%) cases. Infection with coxsackie B virus was most frequently associated with a mixed picture of myo/pericarditis, whereas infiuenzae virus was associated with pericarditis or myocarditis alone. This information wilI provide clinicians with details of the more likely pathogens responsible for these conditions.
Introduction A diverse range of organisms are responsible for infective myocarditis or pericarditis. ~ It is, however, difficult to acquire an overall perspective of the range of organisms involved, and their relative importance, as most studies have involved only case reports or case series of a single organism. 2 The rarity of myocarditis also makes it difficult for one clinical centre to obtain sufficient cases to generate data on the spectrum of organisms involved. 2 This study analyses data from the national laboratory report surveillance scheme in England and Wales and aims to provide an overview of the aetiology of these clinical entities.
1990 and 1993, where pericarditis and/or myocarditis was included as a clinical feature. The first mentioned diagnosis was considered primary and others secondary. The data was checked for duplicates and analysed using the software package "statistical package for social sciences" (SPSS).
Results
Address correspondence to: C. K. Fairley
Between 1990 and 1993, 368 cases of myocarditis and/ or pericarditis were reported to CDSC. The median age was 47 years (range, under 1 year to 93 years). Viruses were reported to cause 253 (69%) cases, of which 147 were coxsackie B virus and 67 were influenzae virus (Table I). Bacteria were responsible for 49 (13%) cases, mycoplasma for 32 (9%) cases, chlamydia for 16 (4%) cases and mycobacterium tuberculosis for nine (2%) cases (Table I). Pericarditis alone was reported in 153 cases, myocarditis alone in 81 cases and a mixed pericarditis/ myocarditis in 134. Infection with coxsackie B virus was most frequently associated with a mixed picture whereas influenzae virus was associated with pericarditis or myocarditis alone (Table I). In most reports where the pathogen was viral, pericarditis and/or myocarditis was the primary clinical feature in 241 (96%) cases. In contrast,
0163-4453/96/030223 +03 $12.00/0
© 1996 The British Society for the Study of Infection
Methods The Communicable Disease Surveillance Centre (CDSC), of the Public Health Laboratory Service (PHLS) receives reports of pathogens identified in laboratories throughout England and Wales as part of the national laboratory report surveillance scheme. 3 These reports include the main clinical features associated with the reported pathogen. These data are stored centrally on a mainframe computer. For this study we extracted all reports between
Infective IVlyocarditis and Pericarditis
224
Table I. Causative organisms and clinical syndrome Organism
Myocarditis
Pereicarditis Myo/pericarditis
Not primary illness-~
Adenovirus (UT) Coxsackie B Echovirus Influenzae A [nfluenzae B Cytomegalovirus Enteroviruses (UT) Other viruses* Chlamydia species
2 4 4 17 11 2 9 5 7 11 2 0 3 4 0 0
5 11 1 25 14 3 5 3 9 20 4 11 12 18 9 3
1 (14%) 1 (1%) 0 6 (14%) 3 (12%) 0 0 1 (13%) 1 (6%) 1 (3%) 2 (33%) 5 (45%) 10 (67%) 7 (29%) 0 0
Mycoplasma pneumoniae Coxiella Burnetii Streptococcus pneumoniae Staphylococcus aureus
Other bacteria* Mycobacterium TB Toxoplasma species
0 132 0 0 0 0 0 0 0 1 0 0 1 0 0
* Other viruses included; herpes simplex type 1, measles, mumps, parainfluenza 2, respiratory syncytial virus, Varicella zoster. Other bacteria included, Borrelia burgdorferi, Citrobacter koseri, Clostridium perfringens and septicum, Escherichia coli, Gemella, Haemophilus influenzae, glebsiella oxytoca, Legionella pneumophilia, Neisseria meningitidis, SalmonelIaenteritidis and typhimurium, coagulase negative Staphylococcus, Streptococcus sanguis)
UT= untyped j"Myocarditis or pericarditis were not the primary illness. Conditions recorded as the primary diagnosis included pneumonia, endocarditis, wound infection from postoperative heart value replacement, arthritis epiglottis, and intra vascular line infection.
reports where the p a t h o g e n was bacterial included pericarditis a n d / o r myocarditis as the p r i m a r y clinical feature in 26 (54%) cases. P r i m a r y clinical features in these bacterial cases included; pneumonia, endocarditis, w o u n d infection from post operative heart valve replacement, arthritis epiglotitis, and intravascular line infection. One h u n d r e d (69%) of the coxsackie B reports occurred in S u m m e r and A u t u m n while 57 (85%) of the influenzae reports occurred in Winter and Spring.
Discussion In the U.K., the c o m m o n e s t reported cause of a combined clinical presentation of myocarditis and pericarditis, was coxsackie B virus. The c o m m o n e s t cause of either m y o carditis or pericarditis, as a single clinical entity, was influenzae virus. Bacterial cases c o m m o n l y occurred in conjunction with other manifestations of the infection (e.g. pneumonia) while viral cases were almost always the primary presenting feature. By analysing cases of myocarditis reported in the U.K. we aimed to provide an overall picture of the likely causes a m o n g a spectrum of cases. This information, will provide clinicians with information on the more likely pathogens responsible for
these conditions and should aid the investigation of the conditions. Direct comparison of our results with those of others is difficult because of different methods of identifying patients in the various studies.1 For example some studies performed molecular techniques on endocardial biopsies from cases of severe myocarditis. 4 In contrast others identified predominantly mild cases of myocarditis by looking for characteristic changes on the ECG of cases with specific viral infections and were thus able to identify cases that m a y have otherwise gone unnoticed, s Despite the different methods used in different studies our results are similar to other studies, with a predominant viral aetiology and other less c o m m o n causes. For example enteroviruses were responsible for 21% of myocarditis in our series and 25% in those w h o had molecular techniques performed on myocardial biopsies. 4 The predominance of coxsackie B virus in our study is supported by the recognition of epidemics of pericarditis, during epidemics of coxsackie virus infection. 6 The results of our study should be interpreted with some caution in view of the limitations associated with the laboratory reporting scheme. 3 In addition, these results m a y be influenced by the clinician w h o is likely to request investigations relevant to w h a t has previously
C. K. Fairley et al been reported to cause these conditions. Notwithstanding these limitations, however, these data provide an overview of the pathogens reported to cause pericarditis and myocarditis and their relative importance in the U.K.
Acknowledgments CKF receives a salary from the National Health and Medical Research Council of Australia.
225 References
1 Savoia MC, Oxman MN. Myocarditis and pericarditis. In: Mandell GL, Douglas RG, Dolin R, eds, Principles and practice of infectious diseases. New York: John Wiley and Sons, 1995: 799-813. 2 Firman G, Fohlman J. The epidemiology of viral heart disease. Scand J Infect Dis. 1993; Suppl. 88: 7-10. 3 Grant AD, Eke B. Application of information technology to the laboratory reporting of communicable disease in England and Wales, Communicable Disease Report; 3: R75-R77. 4 Hyypia T. Etiologic diagnosis of viral heart disease. Scand J Infect Dis. 1993; Suppl. 88: 25-31. 5 Lewes D, Rainford DJ, Lane WF. Symptomless myocarditis and myalgia in viral and Mycoplasma pneumoniae infections, Br Heart J 1974; 36: 924-932. 6 Baine HW, McLean DM, Walker SJ. Epidemic pleurodynia (Bornholm disease) due to coxsackie B5 virus. Pediatrics 1961; 27: 889-902.
The Organisms Reported to Cause Infective Myocarditis and Pericarditis in England and Wales C. K. Fairley*, IVI. Ryan, P. G. Wall and J. Weinberg Public Health Laboratory Service, Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, U.K. Accepted for publication 13 January 1 9 9 6
It is difficult to acquire an overall perspective of the range of organisms responsible for infective myocarditis or periearditis, and their relative importance, as most studies have involved only case reports or case series of a single oNanism. This stu@ analyses reports to the Communicable Disease Surveillance Centre, of the Public Health Laboratory Service. Reports where myocarditis or pericarditis was included as the main clinical features between 1990 and 1993 were studied. Between 1990 and 1993, 368 cases of myoearditis and/or pericarditis were reported to CDSC. Viruses were reported to cause 253 (69%) eases, bacteria were responsible for 49 (13%) cases, mycoplasma for 32 (9%) cases, chlamydia for 16 (4%) cases and Mycobacterium tuberculosis for nine (2%) cases. Infection with coxsackie B virus was most frequently associated with a mixed picture of myo/pericarditis, whereas infiuenzae virus was associated with pericarditis or myocarditis alone. This information wilI provide clinicians with details of the more likely pathogens responsible for these conditions.
Introduction A diverse range of organisms are responsible for infective myocarditis or pericarditis. ~ It is, however, difficult to acquire an overall perspective of the range of organisms involved, and their relative importance, as most studies have involved only case reports or case series of a single organism. 2 The rarity of myocarditis also makes it difficult for one clinical centre to obtain sufficient cases to generate data on the spectrum of organisms involved. 2 This study analyses data from the national laboratory report surveillance scheme in England and Wales and aims to provide an overview of the aetiology of these clinical entities.
1990 and 1993, where pericarditis and/or myocarditis was included as a clinical feature. The first mentioned diagnosis was considered primary and others secondary. The data was checked for duplicates and analysed using the software package "statistical package for social sciences" (SPSS).
Results
Address correspondence to: C. K. Fairley
Between 1990 and 1993, 368 cases of myocarditis and/ or pericarditis were reported to CDSC. The median age was 47 years (range, under 1 year to 93 years). Viruses were reported to cause 253 (69%) cases, of which 147 were coxsackie B virus and 67 were influenzae virus (Table I). Bacteria were responsible for 49 (13%) cases, mycoplasma for 32 (9%) cases, chlamydia for 16 (4%) cases and mycobacterium tuberculosis for nine (2%) cases (Table I). Pericarditis alone was reported in 153 cases, myocarditis alone in 81 cases and a mixed pericarditis/ myocarditis in 134. Infection with coxsackie B virus was most frequently associated with a mixed picture whereas influenzae virus was associated with pericarditis or myocarditis alone (Table I). In most reports where the pathogen was viral, pericarditis and/or myocarditis was the primary clinical feature in 241 (96%) cases. In contrast,
0163-4453/96/030223 +03 $12.00/0
© 1996 The British Society for the Study of Infection
Methods The Communicable Disease Surveillance Centre (CDSC), of the Public Health Laboratory Service (PHLS) receives reports of pathogens identified in laboratories throughout England and Wales as part of the national laboratory report surveillance scheme. 3 These reports include the main clinical features associated with the reported pathogen. These data are stored centrally on a mainframe computer. For this study we extracted all reports between
Infective IVlyocarditis and Pericarditis
224
Table I. Causative organisms and clinical syndrome Organism
Myocarditis
Pereicarditis Myo/pericarditis
Not primary illness-~
Adenovirus (UT) Coxsackie B Echovirus Influenzae A [nfluenzae B Cytomegalovirus Enteroviruses (UT) Other viruses* Chlamydia species
2 4 4 17 11 2 9 5 7 11 2 0 3 4 0 0
5 11 1 25 14 3 5 3 9 20 4 11 12 18 9 3
1 (14%) 1 (1%) 0 6 (14%) 3 (12%) 0 0 1 (13%) 1 (6%) 1 (3%) 2 (33%) 5 (45%) 10 (67%) 7 (29%) 0 0
Mycoplasma pneumoniae Coxiella Burnetii Streptococcus pneumoniae Staphylococcus aureus
Other bacteria* Mycobacterium TB Toxoplasma species
0 132 0 0 0 0 0 0 0 1 0 0 1 0 0
* Other viruses included; herpes simplex type 1, measles, mumps, parainfluenza 2, respiratory syncytial virus, Varicella zoster. Other bacteria included, Borrelia burgdorferi, Citrobacter koseri, Clostridium perfringens and septicum, Escherichia coli, Gemella, Haemophilus influenzae, glebsiella oxytoca, Legionella pneumophilia, Neisseria meningitidis, SalmonelIaenteritidis and typhimurium, coagulase negative Staphylococcus, Streptococcus sanguis)
UT= untyped j"Myocarditis or pericarditis were not the primary illness. Conditions recorded as the primary diagnosis included pneumonia, endocarditis, wound infection from postoperative heart value replacement, arthritis epiglottis, and intra vascular line infection.
reports where the p a t h o g e n was bacterial included pericarditis a n d / o r myocarditis as the p r i m a r y clinical feature in 26 (54%) cases. P r i m a r y clinical features in these bacterial cases included; pneumonia, endocarditis, w o u n d infection from post operative heart valve replacement, arthritis epiglotitis, and intravascular line infection. One h u n d r e d (69%) of the coxsackie B reports occurred in S u m m e r and A u t u m n while 57 (85%) of the influenzae reports occurred in Winter and Spring.
Discussion In the U.K., the c o m m o n e s t reported cause of a combined clinical presentation of myocarditis and pericarditis, was coxsackie B virus. The c o m m o n e s t cause of either m y o carditis or pericarditis, as a single clinical entity, was influenzae virus. Bacterial cases c o m m o n l y occurred in conjunction with other manifestations of the infection (e.g. pneumonia) while viral cases were almost always the primary presenting feature. By analysing cases of myocarditis reported in the U.K. we aimed to provide an overall picture of the likely causes a m o n g a spectrum of cases. This information, will provide clinicians with information on the more likely pathogens responsible for
these conditions and should aid the investigation of the conditions. Direct comparison of our results with those of others is difficult because of different methods of identifying patients in the various studies.1 For example some studies performed molecular techniques on endocardial biopsies from cases of severe myocarditis. 4 In contrast others identified predominantly mild cases of myocarditis by looking for characteristic changes on the ECG of cases with specific viral infections and were thus able to identify cases that m a y have otherwise gone unnoticed, s Despite the different methods used in different studies our results are similar to other studies, with a predominant viral aetiology and other less c o m m o n causes. For example enteroviruses were responsible for 21% of myocarditis in our series and 25% in those w h o had molecular techniques performed on myocardial biopsies. 4 The predominance of coxsackie B virus in our study is supported by the recognition of epidemics of pericarditis, during epidemics of coxsackie virus infection. 6 The results of our study should be interpreted with some caution in view of the limitations associated with the laboratory reporting scheme. 3 In addition, these results m a y be influenced by the clinician w h o is likely to request investigations relevant to w h a t has previously
C. K. Fairley et al been reported to cause these conditions. Notwithstanding these limitations, however, these data provide an overview of the pathogens reported to cause pericarditis and myocarditis and their relative importance in the U.K.
Acknowledgments CKF receives a salary from the National Health and Medical Research Council of Australia.
225 References
1 Savoia MC, Oxman MN. Myocarditis and pericarditis. In: Mandell GL, Douglas RG, Dolin R, eds, Principles and practice of infectious diseases. New York: John Wiley and Sons, 1995: 799-813. 2 Firman G, Fohlman J. The epidemiology of viral heart disease. Scand J Infect Dis. 1993; Suppl. 88: 7-10. 3 Grant AD, Eke B. Application of information technology to the laboratory reporting of communicable disease in England and Wales, Communicable Disease Report; 3: R75-R77. 4 Hyypia T. Etiologic diagnosis of viral heart disease. Scand J Infect Dis. 1993; Suppl. 88: 25-31. 5 Lewes D, Rainford DJ, Lane WF. Symptomless myocarditis and myalgia in viral and Mycoplasma pneumoniae infections, Br Heart J 1974; 36: 924-932. 6 Baine HW, McLean DM, Walker SJ. Epidemic pleurodynia (Bornholm disease) due to coxsackie B5 virus. Pediatrics 1961; 27: 889-902.