Myocarditis is connected with a considerable amount of autoimmune diseases (see chapter Aetiology). Some of them are already mentioned in the chapter Eosinophilic myocarditis (Churg Strauss syndrome and HES). Considering their great amount, this chapter introduces just SLE, ulcerative colitis, Crohn´s disease, coeliac disease and rheumatic fever.

Systematic lupus erythematosus (SLE) is a multiorgan systematic disease affecting skin, lungs and cardiovascular and other systems. Cardiac manifestation is present in 50 % of patients and myocarditis specifically in approximately 10 % [75, 76]. Manifestation and symptoms are similar to other myocarditis types. Signs of heart failure may be observed. Similarly, resources describe even non-specific repolarization changes on ECG together with sinus tachycardia and the presence of segmental or global left ventricular hypokinesis, ventricular dilatation, pericardial effusion and decreased EF [75, 77]. According to the references, CMRI proves besides the above-mentioned findings even myocardial fibrosis. Opinions differ in the question of the benefit of EMB [75]. SLE myocarditis is mostly treated with standard heart failure therapy and with immunosuppressive therapy including corticosteroids [76, 77]. In a Chinese study of 25 patients, hospital mortality was 4 % [77].

Inflammatory intestinal diseases (ulcerative colitis and Crohn´s disease) are rarely complicated by myocarditis. Ulcerative colitis and Crohn´s disease are, in some cases, put in association with GCM (see chapter GCM). Their aetiology may include even mesalamine [78] and lack of selenium [79]. Manifestation, diagnosis algorithm, and the findings are similar to those in other types of myocarditis. They may present even under the picture of a cardiogenic shock [78]. No specific therapy is known. Heart failure therapy is administered if necessary, alternatively, in some cases, symptoms may improve after the discontinuing of mesalamine [78, 80].

Coeliac disease is a chronic inflammatory disease of the small intestine. Its sizeable prevalence was detected in both myocarditis (4,4 %,) [81] and idiopathic DCMP (5,7 %), [82]. Pathogenesis of myocarditis in patients with coeliac disease is unclear. Involvement of autoimmune mechanism is described what was proved even by results of an Italian study [81] when in all patients with myocarditis and coeliac disease cardiac auto-antibodies were detected. There are also speculations about the role of other antibodies which are produced in patients with coeliac disease and the changes of intestinal permeability and so influencing of levels of substances involved in the metabolism of cardiomyocytes could also play an important role [81, 83]. Manifestation is variable. Even the death of patients was described in some cases [84]. In the Italian study [81], 5 patients presented with heart failure resisted to standard pharmacotherapy and 4 with ventricular arrhythmias without syncope. In all patients, the gluten-free diet was applied and in patients with heart failure even immunosuppressive therapy because all patients had no infectious agent in the myocardium according to EMB. The therapy led to the improvement in the heart function and general state of health.

Rheumatic fever is a disease affecting different organs (joints, heart, central nervous system), arising on the autoimmune bases after untreated streptococcus infection [76, 88]. Its prevalence is often primarily in developing countries with the prevalence up to 100 cases per 100 000 inhabitants per year [88]. Cardiac impairment is present in up to 50 % of cases [76, 88] including impairment of valves, coronary arteries and carditis when the pericardium, myocardium (presence of Aschoff bodies, [38]) and endocardium are affected to varying degrees and which is also the most severe complication of rheumatic fever [88]. The prevalence of rheumatic heart disease was in 2015 almost 35 million cases [89]. Pathogenesis according to the resources lies primarily in the production of auto-antibodies against myosin and sarcolemma components [88]. The existence of rheumatic myocarditis was questioned several times already [90] because of the absence of well-marked troponin elevation and ECHO parameters changes, but the diagnosis was not completely rejected. Diagnosis of rheumatic myocarditis is thus highly challenging. Patients with rheumatic carditis may manifest even with heart failure or arrhythmias [88]. Therapy includes corticosteroids, salicylates, Penicillium, alternatively heart failure therapy [88]. The issue of rheumatic fever and carditis is far extensive. This chapter summarized only some pieces of knowledge.

Author of the opening picture: Lennart81

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References:

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