View source for Carditis

==Background==
Carditis refers to inflammation of the heart, including the endocardium, myocardium, and/or pericardium. In the emergency department, carditis may present subtly or with life-threatening complications. Causes range from infectious (viral, bacterial, rheumatic) to autoimmune (SLE, vasculitis) or drug-induced. It is one of the major Jones criteria for acute rheumatic fever and can present in children or adolescents following a streptococcal infection. Prompt recognition is critical due to risk of valvular damage, heart failure, and arrhythmias.

==Clinical Features==
Presentation depends on which layer(s) of the heart are involved:

[[Endocarditis]]:

* Fever, new murmur, petechiae, Osler nodes, Janeway lesions
* May present with embolic phenomena (e.g., stroke, hematuria)

[[Myocarditis]]:

* Fatigue, chest pain, palpitations
* May mimic ACS or present with heart failure symptoms
* 
[[Pericarditis]]:

* Sharp, pleuritic chest pain improved by sitting up
* Pericardial friction rub
* May show diffuse ST elevation and PR depression on ECG
* 
In rheumatic carditis, signs may include:

* Tachycardia out of proportion to fever
* New or changing murmur (e.g., mitral regurgitation)
* Signs of heart failure in a previously healthy child

==Differential Diagnosis==
* Infective endocarditis
* 
* Acute coronary syndrome
* 
* Pericarditis (viral, autoimmune, uremic)
* 
* Myocarditis (viral, toxic, autoimmune)
* 
* Sepsis-induced cardiac dysfunction
* 
* Valvular disease (e.g., mitral valve prolapse, aortic stenosis)
* 
* Rheumatic fever
* 
* Systemic lupus erythematosus (SLE)
* 
* COVID-19 or post-viral inflammatory syndrome

==Evaluation==
===Workup===
* Vitals + ECG (look for arrhythmias, PR prolongation, ST changes)
* 
* Cardiac biomarkers (troponin, BNP)
* 
* CXR (look for cardiomegaly, pulmonary edema)
* 
* Echocardiogram (TTE or TEE if endocarditis suspected)

* Labs:

** CBC, CMP
* 
** ESR/CRP (inflammatory markers)
* 
** Blood cultures x2–3 (if endocarditis suspected)
* 
** ASO or anti-DNase B titers (if rheumatic fever suspected)
* 
** Throat culture or rapid strep test
* 
* Consider:
* 
** ANA, rheumatoid factor (autoimmune causes)
* 
** COVID-19 or viral panel
* 
** Pericardial fluid studies if effusion and pericardiocentesis performed

===Diagnosis===
Myocarditis/pericarditis: clinical history, ECG findings, elevated troponin, and/or imaging

Endocarditis: Modified Duke criteria (positive blood cultures + evidence on echo or vascular/immunologic findings)

Rheumatic carditis: Based on Jones Criteria (carditis + supporting evidence of recent group A strep infection)

==Management==

=== Infectious Endocarditis ===
* Start broad-spectrum antibiotics after cultures (e.g., vancomycin + ceftriaxone)
* 
* Consult infectious disease and cardiology

=== Myocarditis ===

* Supportive care (oxygen, fluids cautiously, inotropes if shock)
* 
* Avoid NSAIDs unless pericarditis predominant
* 
* Cardiology consult and hospital admission

=== Pericarditis ===

* NSAIDs + colchicine if viral/idiopathic
* 
* Avoid steroids unless autoimmune etiology
* 
* Monitor for tamponade (Beck's triad, pulsus paradoxus)

=== Rheumatic Carditis ===

* Penicillin (to eradicate strep infection)
* 
* Aspirin or NSAIDs for arthritis/carditis
* 
* Steroids for severe carditis or heart failure symptoms
* 
* Bed rest and cardiology consultation

==Disposition==
Admit if:

* Evidence of heart failure, hypotension, or hemodynamic instability
* 
* Troponin elevation or suspected myocarditis
* 
* Signs of tamponade or large pericardial effusion
* 
* Suspected or confirmed infective endocarditis
* 
* Suspected acute rheumatic fever with carditis
* 
Discharge may be appropriate if:

* Stable, low-risk pericarditis with no effusion
* 
* Mild, resolving symptoms and normal cardiac studies
* 
* Reliable follow-up with cardiology and primary care is available
* 
* All patients with suspected carditis should have follow-up within days and cardiology consultation arranged from the ED if not admitted.