**7. References**


The effectiveness of steroids as anti-inflammatory and immunosuppressant drugs has been widely accepted. Its effectiveness when treating patients with fulminant myocarditis has been also reported in many studies (Ino et al., 1995). However, administration of steroid was not proved effective in patients with lymphocytic myocarditis in a clinical trial (Mason et al., 1995). We would not hastily administer steroids to patients with acute-phase myocarditis with a suspected viral infection. On the other hand, it is expected that administration of steroids alleviates cardiac dysfunction in patients with giant cell myocarditis and eosinophilic myocarditis (Cooper et al., 1997). Particularly, high-dose steroids should be given prior to other treatments in patients with the fulminant type of giant cell myocarditis.

It is not easy to explain myocarditis concisely and clearly because there are varieties of causes, clinical types, clinical courses, and the severity of circulatory failure. Some patients present with common cold-like symptoms, whereas others require mechanical circulatory support in the ER because of a suddenly developing circulatory crisis. Information of the patient's background and clinical history is essential when deciding on a treatment plan for myocarditis in most cases, although we are sometimes unexpectedly confronted with

Currently, the most troublesome issue in the course of treating myocarditis is when to perform a myocardial biopsy for a definitive diagnosis. Although noninvasive diagnostic methods such as CMR have been developed to reduce the risk of serious complications and physical strain on the patient, an effective diagnosis cannot be established during the acute phase. Regarding the treatment for myocarditis, we cannot presently exclude original causes in many cases and can only provide unpredictable "bridge" support, such

Many patients with myocarditis can survive if we remember the possibility of myocarditis in the differential diagnosis and provide immediate, adequate treatment. When we face illness of unknown origin in patients with a severe arrhythmia or circulatory failure, we should immediately assemble the medical staff and prepare cardiac support. Any delay in treatment can allow abrupt deterioration of the circulation. Additionally, we should establish a system of simultaneous processing of the histological diagnosis to decide on the

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**5.2.2 High-dose steroids** 

**6. Conclusions** 

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**1. Introduction** 

& Dec, 2006).

diagnosis.

**4** 

*France* 

**and Diagnosis** 

Andréoletti Laurent

*Medicine Faculty of Reims* 

**Viral Myocarditis: Physiopathology** 

In Europe and the USA, viral aetiologies largely prevail over other causes of myocarditis as previously indicated by recent data demonstrating the molecular detection of cardiotropic viruses in human cardiac biopsy samples (Kühl et al., 2005a). Clinical presentations of the myocarditis range from non-specific systemic symptoms (fever, myalgias, palpitations, or exertional dyspnea) to fulminant hemodynamic collapse (5 to 10 cases per million inhabitants and per year) and sudden cardiac death (Feldman & McNamara, 2000; Magnani

Acute myocarditis remains a complex and challenging diagnosis in cardiology (Magnani & Dec, 2006). This cardiomyopathy is defined histologically by the Dallas criteria as an''inflammation of the myocardium'' associated with necrosis and an absence of ischaemia (Aretz et al., 1987; Cooper, 2009; Dennert et al., 2008; Felmann & McNamara, 2000). The use of the Dallas criteria in the diagnosis of myocarditis is associated with poor sensitivity and specificity, mainly because of the sampling error related to the often focal distribution of the specific histological lesions in cardiac tissue and because of the variability in pathological interpretation (Baughman, 2006; Mahrholdt et al., 2004). Moreover, the Dallas classification does not consider local quantification and differentiation of inflammatory cells and does not take into account viral infection and autoimmune regulation in cardiac tissues (Dennert et al., 2008). To improve the histological diagnosis, additional virological and immunological evaluations of cardiac tissues are required using immunohistochemical and PCR techniques, which allow identification and quantification of inflammatory cells and viral infection markers (Dennert et al., 2008). The diagnostic gold standard is endomyocardial biopsy with the histological Dallas criteria in association with new immunohistochemical and viral PCR analyses of cardiac tissues (Cooper et al., 2007). This new diagnostic approach can lead to better identification of the aetiological cause of the myocarditis and can improve the clinical management of viral myocarditis. This chapter chronicles the advances in understanding the physiopathology of viral acute and chronic myocarditis and in the development of new molecular techniques for an accurate and valuable virological

*Head of the clinical and molecular Virology Unit, University medical centre and EA research team at the* 

Zagrosek, A., Wassmuth, R., Abdel-Aty, H., et al. (2008). Relation between myocardial edema and myocardial mass during the acute and convalescent phase of myocarditis: a CMR study. *J Cardiovasc Magn Reson,* 10,19.
