**8. Conclusion**

Myocarditis in children is challenging given a variety of clinical manifestations that may share common pediatric illnesses such as respiratory infections and gastrointestinal disorders. A high index suspicion is so vital in the diagnosis. With the introduction of new additional diagnostic modalities including cardiac magnetic resonance imaging and biomarkers, cases will be identified easily in the future that would have been formerly missed. Myocarditis causes dilated cardiomyopathy in a significant portion of children. Prognosis for cases with acute viral myocarditis is much better than cases with established cases of dilated cardiomyopathy. Therefore, prompt diagnosis and early effective supportive care are crucial. Even if, much improvement has been achieved in pathogenesis, diagnosis and treatment of myocarditis, many questions remain to be answered and indicate the necessity for additional investigations.

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**3** 

*Japan* 

**Acute Myocarditis in Emergency Medicine** 

Emergency doctors provide primary care to many patients with an acute-onset condition in the emergency room (ER) every day. We occasionally must address circulatory failure in patients that ranges from "acutely developing" to "severe." Usually, it is not difficult to diagnose or to choose the proper therapeutic procedures, because most of these cases are caused by heart diseases, such as ischemic heart disease or an arrhythmia. However, in

It is known that cardiomyopathies account for some of those undiagnosed cases. Classically, cardiomyopathies have been regarded as idiopathic myocardial diseases because of the difficulty of detecting their etiology or the mechanisms causing the problem. Recent developments in biochemical technology have provided the option of approaching these unknown mechanisms using genetic analyses (Richardson et al., 1996). Cardiomyopathies are presently classified into several groups, defined by the cause, tissue type, and clinical course. In 2006, a committee of the American Heart Association (AHA) advocated new criteria for cardiomyopathies. With those criteria, primary cardiomyopathies are classified into a genetic type, a mixed type, and an acquired type

We encounter several types of cardiomyopathy in the ER. Immediate adequate primary treatment of these cases must be prudent because circulatory insufficiency can rapidly

In most cases, myocarditis is caused by an inflammatory response and is classified as an acquired type of primary cardiomyopathy. It is also categorized as either acute or chronic. The comprehensive concept of chronic myocarditis has not yet been established because cases of chronic myocarditis have not been sufficiently reported. For most cases of chronic

We have only practical guidelines for treating chronic myocarditis in Japan (JCS, 1996). These patients usually have long-term therapeutic histories. Therefore, the patients' own doctors who are familiar with their clinical histories should be responsible for treatment in the ER. On the other hand, most cases of acute myocarditis are of sudden onset, and severe cases are taken to the ER by the emergency medical service. Doctors in the ER must then be responsible for the primary treatment of these patients. Because there is the risk of sudden development of circulatory insufficiency with acute myocarditis, immediate and adequate

myocarditis, the causes and developmental mechanisms remain unclear.

some cases the causes of circulatory failure cannot be determined immediately.

**1. Introduction** 

(Maron et al., 2006).

progress to cardiac arrest.

initial treatment is necessary for survival.

Yukihiro Ikegami and Choichiro Tase

*Fukushima Medical University,* 

