Clozapine-induced myocarditis in observational cross-sectional and follow-up evaluations: comparison with other antipsychotics in naturalistic settings / Miocarditis inducida por clozapina durante la evaluación observacional, transversal y longitudinal: comparación con otros antipsicóticos en ambientes naturalísticos

Myocarditis occurs more frequently during clozapine (CLZ) administration than during treatment with other antipsychotic drugs (APs). In this observational study, we transversally screened outpatients for myocarditis by comparing a CLZ group of 132 subjects, with a non-CLZ group taking other APs (n = 371) only, and in 21 CLZ-treated patients and 18 subjects treated with other APs who had been followed for more than one year. The protocol included a) assessment of symptoms such as dyspnea, tachycardia, chest discomfort, fever, cough, and edema, b) blood pressure and heart auscultation; c) a standard electrocardiogram after a 5-minute rest, d) white cell count, and qualitative determination of troponin I, creatine-kinase-MB and myoglobin, and e) a cardiologist evaluation of subjects with suspected myocarditis. Only one case of myocarditis was detected, providing an approximation of the frequency of myocarditis of 1.6% in the first month of treatment. This was a 30-year-old man with schizophrenia who developed symptoms at day 6 after starting a treatment with 200 mg of CLZ a day without titration. Myocarditis was not observed during prolonged CLZ or other AP administration. These results support the proposal of starting CLZ treatment with a low dose and the feasibility of a simple protocol for myocarditis detection in psychiatry primary care.

El desarrollo de miocarditis ocurre con más frecuencia durante el tratamiento con clozapina (CLZ) que durante el uso de otros antipsicóticos (APs). En el presente estudio observacional evaluamos la presencia de miocarditis mediante un protocolo transversal comparando 132 sujetos tratados con CLZ con 371 pacientes tratados con otro AP, y en 21 sujetos tratados con CLZ y 18 pacientes tratados con otro AP en un protocolo longitudinal mayor 1 año de duración. La evaluación incluyó: a) detección de síntomas como disnea, taquicardia, malestar torácico, fiebre, tos y edema; b) presión arterial y auscultación cardiaca; c) electrocardiograma estándar luego de un reposo de 5 minutos; d) contaje de glóbulos blancos y determinación cualitativa de troponina I, creatin-kinasa-MB y mioglobina, y e) evaluación por un cardiólogo en sujetos sospechosos para miocarditis. Detectamos un solo caso de miocarditis, lo que permite una aproximación sobre la frecuencia de miocarditis de 1,6 % durante el primer mes de tratamiento. Se trató de un sujeto masculino con esquizofrenia que desarrolló síntomas durante el día 6 después de haber iniciado el tratamiento con CLZ a la dosis de 200 mg por día sin titulación. No se detectaron sujetos sospechosos de miocarditis durante el tratamiento prolongado con CLZ u otro AP. Estos resultados sustentan la recomendación de comenzar el tratamiento con clozapina a dosis bajas, y la factibilidad de utilizar un protocolo sencillo para detectar miocarditis en la atención psiquiátrica primaria.

Hypersensitivity myocarditis confirmed by cardiac magnetic resonance imaging and endomyocardial biopsy

Myocarditis often occurs due to viral infections and postviral immune-mediated responses. Hypersensitivity myocarditis is a rare form of myocarditis. Numerous drugs can induce myocarditis, which is typically reversible after withdrawal of the causative agent. Here, we report a case of hypersensitivity myocarditis that was probably triggered by amoxicillin and that resolved completely with heart failure management as well as discontinuation of the drug. A 68-year-old woman presented with acute chest pain mimicking acute coronary syndromes, but the coronary angiography was normal. A recent history of taking medications, skin rash, and peripheral eosinophilia suggested a diagnosis of hypersensitivity myocarditis, which was confirmed by cardiac magnetic resonance imaging and endomyocardial biopsy.

Reversible myocarditis in a patient receiving clozapine.

Myocarditis is a rare and potentially life-threatening complication of clozapine. We report the case of a 2 6-year-old patient who developed reversible myocarditis during treatment with clozapine for chronic resistant schizophrenia. The patient recovered rapidly on withdrawal of clozapine and with supportive management.

Daño cardiovascular asociado al uso de alcohol y drogas / Cardiovascular failure associated to alcohol and drug comsumption

El alcohol y las drogas que generan dependencia, tienen efectos deletéreos sobre el sistema cardiovascular tanto por acción tóxica directa como por agravar o potenciar las alteraciones subyacentes que forman parte de la patología prevalente en adultos expuestos a estos riesgos de adicción. El diagnóstico diferencial es esencial para tomar las medidas correctoras que, en todo caso, prevengan los efectos cardiovasculares de su consumo y disminuyan el riesgo de agravación de las cardiopatías de base asociadas, fundamentalmente por su trascendencia, las alteraciones dependientes de la cardiopatía coronaria. Especialmente respecto al alcoholismo, y dadas las consecuencias de la promoción y de la liberalización de su ingesta por los eventuales beneficios preventivos de su uso controlado, debe mirarse con reservas la supuesta evidencia epidemiológica que preconiza su indicación profiláctica en la cardiopatía ateroesclerótica, como no resiste toda lógica la indicación irrestricta de anabólicos o drogas causantes de dependencia, para aumentar la resistencia o la capacidad física de individuos expuestos a tareas exhaustivas

Carbamate insecticide and myocarditis.

The report of a 25-year-old Thai woman who came to the emergency room of Chulalongkorn Hospital dead on arrival. The gross and microscopic anatomic findings of lungs were compatible with carbamate poisoning which was confirmed by the analysis of the liver. Another important finding was profuse myocarditis which might be another cause of death. We found no relationship between myocarditis and carbamate poisoning in previous reports. (Computerized search by Medline).

Alteraçöes miocárdicas em AIDS / Changes myocardial in AIDS

A síndorme de imunodeficiência adquirida (AIDS) avança progressivamente, tornando-se uma epidemia de conseqüências imprevisíveis, até o momento. Apesar disso, o conhecimento da doença e as possibilidades terapêuticas no controle das infecçöes oportunistas e também da doença de base, têm possibilitado maior sobrevida aos portadores de AIDS, propiciando que as complicaçöes cardíacas sejam cada vez mais reconhecidas nos aidéticos, já que anteriormente os pacientes sucumbiam precocemente por intercorrências infecciosas. Esta atualizaçäo se propöe a mostrar o estágio de conhecimento do envolvimento do miocárdio na AIDS, manifestado como miocardites e miocardiopatia dilatada, provocada por vários agentes infecciosos e também por açäo tóxica de drogas utilizadas para tratamento das infecçöes oportunistas ou mesmo para o controle do próprio vírus do HIV

A study of aluminum phosphide (AlP) poisoning with special reference to electrocardiographic changes.

Ninety patients with aluminum phosphide poisoning have been studied over a period of 3 years. Epigastric pain and vomiting were the common initial clinical features, followed 12 to 24 hours later by cardiogenic shock, oliguria, altered mental state and respiratory distress. Death occurred within 24 to 72 hours presumably due to poison-induced toxic chemical myocarditis as reflected by electrocardiographic changes. The overall mortality was 63.3%. Intravenous magnesium sulphate, probably due to its membrane stabilizing action, appears to be related to the reduction in mortality from 90% to 52% in the latter 62 cases.

Insulin administration reverses the metabolic and electrocardiographic changes in acute myocarditis induced by Indian red scorpion (Buthus tamulus) venom in experimental dogs.

Acute myocarditis was produced by injection of 4 mg/kg Indian red scorpion (Buthus tamulus) venom in dogs. Several rhythm changes, conduction defects, infarction-like pattern and many other ECG abnormalities; hyperglycemia, reduced insulin secretion, rise in free fatty acids along with fall in triglycerides; depletion of glycogen content of atria, ventricles, liver and skeletal muscles was noticed within 20-30 minutes after scorpion envenomation. Ten units of crystalline insulin was given i.v. at this time. All the arrhythmias, conduction defects and other ECG abnormalities disappeared after intervention with insulin. The sinus rhythm persisted for a duration of 120 minutes till the animals were sacrificed. Reduction in free fatty acids along with a rise in triglycerides; glycogenesis in liver, cardiac and skeletal muscles was observed at the time when ECG tracing was normal. It is suggested that catecholamines released during autonomic storm in scorpion poisoning suppress insulin secretion. These in turn result in glycogenolysis; lipolysis resulting in increased free fatty acids and produce arrhythmias. Insulin administration results in glycogenesis; lipogenesis and stops arrhythmias.

Acute pancreatitis and reduction of H+ ion concentration in gastric secretions in experimental acute myocarditis produced by Indian red scorpion, Buthus tamulus, venom.

Crude venom (4 mg/kg) of scorpion (B. tamulus) was given in saline to anaesthetized dogs and rabbits. It produced a reduction in gastric H+ ion concentration in dogs with acute myocarditis. Simultaneously an increase in circulating amylase and lipase level was also observed. However 60% venom poisoned rabbits showed an elevated lipase level without a parallel increase in amylase. It is suggested that the venom acts directly on exocrine pancreas to cause acute pancreatitis.