Myocarditis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.

Overview

The physical examination in patients with myocarditis may reveal tachycardia, a cardiac gallop, mitral regurgitation due to left ventricular dilation and pedal edema suggestive of cardiac failure. A pericardial friction rub may be noted in presence of concomitant pericarditis, a condition sometimes referred to as myopericarditis.

Physical Examination

General appearance

Patients with mild cases of myocarditis may have a nontoxic appearance or may simply appear to have a viral syndrome. Patients with acute onset or advanced disease may present with signs of cardiac dysfunction.

Vital signs

• Hypotension (if severe left ventricular systolic dysfunction is present)
• Tachycardia
• Tachypnea
• Fever (if an underlying infectious cause is present)

Heart

• Jugular venous distension may be noted if the patient has congestive heart failure
• The apical impulse may be displaced laterally if there is left ventricular dilation
• Auscultation:
  • S₃ or occasionally a summation gallop may be noted, particularly in significant biventricular dysfunction.
  • Tachycardia or arrhythmia
  • Mitral or tricuspid murmurs (holosystolic murmurs) may also be noted in the presence of significant ventricular dilation leading to regurgitant flow across AV valves.
  • Pericardial friction rub and low intensity heart sounds may be evident if pericardium is involved causing pericarditis and effusion respectively.

Lungs

• The lung fields may be dull on percussion in presence of infection or pleural effusion
• Basilar crackles may be heard on auscultation, which may be suggestive of pulmonary edema
• Decreased breath sounds may be noted in presence of an accompanying pleural effusion
• Egophony may be present if consolidation of the lung is present

Abdomen

Ascites may be observed if heart failure and fluid overload is present

Extremities

Pedal edema may be observed if congestive heart failure and fluid overload are present.

Physical Examination Findings Specific to Various Underlying Causes

• Hypersensitive/eosinophilic myocarditis: A pruritic maculopapular rash may be present.
• Acute rheumatic fever: Components of the Jones criteria such as erythema marginatum, polyarthralgia, chorea, subcutaneous nodules may be present.