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The human body resembles a well-guarded fortress. When its defense forces fight bacteria or viruses, it is said to be an inflammatory process. The attack may also be directed at the heart.
Inflammation can affect the pericardium, the heart muscle itself, or even the endocardium, the thin layer that lines the cavity – the ventricle and atria – of the heart. In all three cases, its causes are similar – bacterial or viral infection, parasites, fungi, concomitant diseases. Inflammation can affect everyone: women and men, young and old, healthy and sick – the latter, unfortunately, more often.
Pericarditis
The pericardium consists of two layers: the visceral layer, closely adjacent to the heart, and the wall layer. The space between them under physiological conditions may contain 15-50 ml of fluid.
Pericarditis develops as a result of viral or bacterial infection, mycobacterium tuberculosis (often!) Or rheumatic disease. It can also appear in the course of a heart attack or accompany uremia. Other causes include connective tissue disease, chronic renal or circulatory failure, hypothyroidism, use of certain medications, and radiation therapy. The inflammatory process can be caused by a complication of heart surgery and tumor metastasis. There are also cases where the cause of the infection is unknown.
The symptoms of pericarditis can be divided into three groups: chest pain (when the amount of fluid in the pericardial sac has not yet increased significantly), shortness of breath (more fluid causes pressure on the heart and chest organs) and general symptoms. Pain of varying intensity usually occurs suddenly. It is located in the area of the sternum, it radiates to the neck, both shoulders and the left shoulder blade. It worsens with breathing and chest movements and, unlike heart attack pain, it decreases when standing up and leaning forward.
Later in the disease, when fluid accumulates in the pericardial sac that prevents the heart from working fully (freely), symptoms of circulatory failure may appear: shortness of breath, faster fatigue and coughing. Inflammation is generally accompanied by high fever, chills, and general weakness. Such symptoms (although they may also occur in other diseases) should be consulted with a doctor. However, if they are all growing rapidly, urgent medical attention is needed.
Treatment in the initial period requires a hospital stay. Depending on the cause of inflammation, antibiotics, anti-tuberculosis and anti-fungal drugs are used. They are also administered anti-inflammatory drugs or in cases of severe inflammation – steroids. If the amount of fluid in the pericardial sac increases rapidly and symptoms of circulatory failure worsen, puncture of the pericardial sac and removal of the fluid are performed. Further recovery can take place at home, with limited physical activity – return to normal activities occurs gradually, as the symptoms of inflammation subside. With timely treatment, pericarditis is cured within weeks or months (this does not apply to tumor metastases to the pericardium), and usually no permanent changes remain in the pericardium.
If left untreated, however, it can have serious consequences – the fluid accumulating in the pericardial sac will significantly disturb the functions of the heart, may lead to chronic pericarditis with frequent exacerbations or to fibrosis of the pericardial sac and its adhesion to the heart wall with subsequent calcification. In this case, the surgery is performed to remove the pericardial sac.
Inflammation of the heart muscle
Most often it has a viral background (e.g. untreated influenza) or a concomitant disease (diphtheria, typhoid, hepatitis, rubella, measles, shingles). It can then lead to heart failure and its permanent damage.
Another cause of myocarditis is rheumatoid arthritis (which can also lead to endocarditis or pericarditis) or infection caused by fungi or protozoa. The following factors also contribute to the inflammatory process: diabetes, hyperthyroidism, gout, kidney and liver diseases, hardening of blood vessels and many infectious diseases.
The disease has a different course: from forms that are almost clinically elusive and often undiagnosed during the course of the inflammatory process, to very acute, fulminant myocarditis with symptoms of severe circulatory failure. Symptoms that should be noted by both the patient and the doctor are exertional dyspnoea, chest pain, palpitations and fainting. Laboratory tests show an increase in ESR values, and the diagnosis is confirmed by histopathological examinations after cardiac biopsy.
There are still no clear-cut methods of treating myocarditis, but they should certainly be started as soon as a medical diagnosis is obtained. Patients are advised to limit their physical activity. Standard methods of treating heart failure and eliminating heart rhythm disturbances are used. Of course, the root cause of the infection must be found and treated.
Inflammation of the heart muscle may end with a full recovery. Unfortunately – it can also leave behind various “traces”, for example in the form of arrhythmias or left ventricular failure of varying severity. In some patients, the stage of failure is so high and unresponsive to treatment that it is even necessary to undergo a heart transplant.
See also what is characterized by mitral valve prolapse
Endocarditis
The endocardium is the inner lining of the heart cavities. It becomes inflamed (IE) when bacteria enter the circulating blood, usually from the mouth, but sometimes also from other parts of the body (the source of infection may be the skin, gastrointestinal tract, and genitourinary system).
Infection can occur at sites that have been significantly changed by a previous disease process or surgery, such as damaged or artificial valves, intracardiac electrodes. The process leads to further damage to the valves (bacteria that enter the blood during these procedures settle on them) and the lining of the heart. Untreated endocarditis can be life-threatening.
In the inflamed endocardium, deposits of platelets, fibrinogen and bacteria form, which lead to perforation (perforation) of the valve leaflets and rupture of the tendon threads.
Other predisposing factors to infectious endocarditis are: artificial and biological heart valves, congenital heart defects, acquired heart defects (also caused by rheumatic fever), hypertrophic cardiomyopathy (HCM), cardiac catheterization, drug addiction.
People who are at a much higher risk of getting infected with infective endocarditis must pay special attention to the condition of their teeth and the entire oral cavity. They must not forget to visit the dentist regularly (and they should be given an antibiotic before procedures that cause bleeding).
Endocarditis may come on suddenly, but usually, symptoms develop within a few weeks. The typical ones include: night sweats, weight loss, various pain ailments, increased body temperature, auscultation changes, excessive sweating, weakness, cold extremities, back pain and Osler’s nodules (very rare but specific symptom for endocarditis – painful subcutaneous lumps on the fingers hands and tendons).
In addition, echocardiography (especially transesophageal!) Shows changes in the heart valves, and blood count – anemia (in 80% of patients), protein and blood cells appear in the urine, and ESR is elevated.
Patients should be lying down, hospital treatment is necessary (4-6 weeks), which enables identification of the bacterial strain causing the disease and application of antibiotics, most often intravenously.
The prognosis of untreated patients is poor. With antibiotic treatment, the prognosis depends on the degree of previous damage to the heart, the body’s resistance, the patient’s age, the sensitivity of the microorganism to antibiotics, and the time of initiation of treatment. Current therapies allow 70% of patients to survive, but the prognosis is less favorable in patients with prosthetic valves, in infections with fungi and Gram (-) bacteria, and in accompanying heart failure (the most common cause of death).
The main complication of bacterial endocarditis is vascular blockage – in the spleen, brain, lungs, and also in the kidneys. However, if your heart valve has been severely damaged in the course of the infection, you may also need to have a new replacement surgery.
Text: Marek Sitkowski
Consultation: Małgorzata Sobieszczańska-Małek, MD, PhD