临床病理讨论会ppt课件

臨床病理討論會 小兒科：盧俊維醫師 放射科：吳金珠醫師 病理科：蕭正祥醫師 A 10 y/o girl Chief complaint: Chest discomfort, vomiting and dry cough for one day Brief History Growth Mycoplasma pneumonia IgM: (9/12) positive, (9/21) negative Other virology study: all negative Coxsackie A, Coxsackie B1-B6, CMV IgG 1:3-14 Dark side of the myocarditis Etiology hard to find VIRAL CAUSES Enterovirus Coxsackie A Coxsackie B Echovirus Poliovirus Adenovirus Cytomegalovirus Herpesvirus Influenza A Epstein-Barr virus Varicella Mumps Measles Parvovirus Rabies Hepatitis B,C Rubella Rubeola Respiratory syncytial virus Human immunodeficiency virus Rickettsial Rickettsia ricketsii Rickettsia tsutsugamushi Bacterial Meningococcus Klebsiella Leptospira Mycoplasma Salmonella Clostridia Tuberculosis Brucella Legionella pneumophila smallpox Streptococcus Protozoal Trypanosoma cruzi Toxoplasmosis Amebiasis Other parasites Toxocara canis Schistosomiasis Hetereophyiasis Cysticercosis Echinococcus Visceral larva migrans Trichinosis Fungi and yeasts Actinomycosis Coccidiodomycosis Histoplasmosis Candida NONVIRAL CAUSES Dark side of the myocarditis Etiology hard to find Toxic Scorpion Diphtheria Drugs Sulfonamides Phenylbutazone Cyclophosphamide Neomercazole Acetazolamide Amphotericin B Indomethacin Tetracycline Isoniazid Methyldopa Phenytoin Penicillin Hypersensitivity/Autoimmune Rheumatoid arthritis Rheumatic fever Ulcerative colitis Systemic lupus erythematosus Mixed connective tissue disease Scleroderma Whipples disease Other Sarcoidosis Kawasaki disease Cornstarch NONINFECTIOUS ETIOLOGIES Dark side of the myocarditis Etiology hard to find Pediatr Cardiol 2001;22:34-9 Dark side of the myocarditis Complexity of pathogenesis NEJM 2000;343:1388-98 Dark side of the myocarditis Complexity of pathogenesis Factors contributing to host susceptibility Autoantibodies: to adenosine nucleotide translocator, myosin Expression of cell adhesion molecules (ICAM-1) Expression of coxsackie-adenovirus receptor (CAR) Dark side of the myocarditis Often refractory to conventional treatment Standard therapy: ACE inhibitor, inotropic agents, diuretics often not effective in fulminant myocarditis Immunosuppression: IVIG, steroids, cyclosporin still controversial Bright side of the myocarditis Good long term prognosis of fulminant myocarditis Improvement of mechanical support: LVAD, BVAD, ECMO Bright side of the myocarditis Good long term prognosis of fulminant myocarditis NEJM 2000;342:690-5 Bright side of the myocarditis Good long term prognosis of fulminant myocarditis Bright side of the myocarditis Good long term prognosis of fulminant myocarditis Why? Different viral agent? Different host response? Autoimmune in nature? Bright side of the myocarditis Ventricular assistant device (VAD) 112:440-8 Future strategies Antiviral agents: interferon, ribavirin, pleconaril Vaccine: to specific virus, T-cell receptors,tolerance to myosin Earlier mechanical support More specific immunosuppression: OKT3, NO synthetase blocker, Clinical diagnosis Fulminant myocarditis, possible viral origin, e