Invited commentary What is the definition of SPAM? Even if you cannot define it, you must recognize it!
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hest pain with electrocardiographic ST elevation is managed today with coronary arteriography at a hospital capable of percutaneous coronary intervention (PCI). When no culprit coronary stenosis is found, the angiographic catheter is removed, and it is often the responsibility of another physician to determine the cause of the pain and electrocardiographic changes. Pericarditis is often diagnosed, but it does not explain the elevation in cardiac biomarkers. Treatment with a nonsteroidal antiinflammatory drug with or without colchicine might offer benefit, but in some cases it is not enough. Days of insufficient treatment might pass before the evolution of electrocardiographic changes looks more like myocarditis than pericarditis. In this issue of BUMC Proceedings, Aguirre and coworkers (1) present a case of streptococcal pharyngitis–associated myocarditis. They describe the presentation in a 43-year-old man and a logical sequence of tests used to diagnose acute myocarditis and its association with group A streptococcal pharyngitis. They deserve special commendation for their tabular collation of the published literature of this disease, including this case. There are fewer than 50 cases of streptococcal pharyngitis– associated myocarditis in the medical literature. Yet, annually in the US, 11 million patients present to an emergency department or ambulatory care setting with sore throat, and group A streptococcus is responsible for 5% to 15% of sore throats in adults and 20% to 30% in children (2, 3). The incidence of streptococcal pharyngitis–associated myocarditis might be larger than is recognized. Treatment with penicillin provides clinical improvement in 2 to 3 days and improvement in left ventricular function (4). Delayed diagnosis or failure to diagnose can result in persistent left ventricular dysfunction and recurrence. Is chronic antibiotic suppression of group A streptococcus needed, as is used to prevent recurrent acute rheumatic fever? Is it necessary only when there is persistent exposure to unhygienic carriers like schoolchildren? When is tonsillectomy needed? A high index of suspicion for streptococcal pharyngitis– associated myocarditis is necessary when a young patient,
Proc (Bayl Univ Med Cent) 2015;28(2):191
especially male, with no risk factors for coronary artery disease presents to the emergency department with chest pain, electrocardiographic ST elevation, and elevated cardiac biomarkers and has no culprit coronary stenosis. The next questions must be about close recent exposure to someone with streptococcal pharyngitis and/or a sore throat in the last week. Cultures and serologic testing for streptococcal infection can detect chronic asymptomatic exposure. What would foster recognition of streptococcal pharyngitis– associated myocarditis? A catchy name might help. I propose an additional dictionary definition of the word spam, with all capital letters: SPAM (noun) 1. Trademark for spiced ham (1937) 2. Unsolicited or undesired electronic message (1990s) 3. Streptococcal pharyngitis–associated myocarditis (2010) SPAM might be included in the guidelines for the management of STEMI. When it is diagnosed in greater numbers, controlled trials can be designed to answer these questions about the benefits of chronic antibiotic suppression and of tonsillectomy. —William A. Schiavone, DO Heart and Vascular Institute Cleveland Clinic E-mail: [email protected] 1.
2. 3.
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Aguirre JL, Jurado M, Porres-Aguilar M, Olivas-Chacon C, Porres-Muñoz M, Mukherjee D, Taveras J. Acute nonrheumatic streptococcal myocarditis resembling ST-elevation acute myocardial infarction in a young patient. Proc (Bayl Univ Med Cent) 2015;28(2):188–190. Hing E, Cherry DK, Woodwell DA. National ambulatory medical care survey: 2003 summary. Adv Data 2005;365:1–48. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55(10):e86–e102. Mokabberi R, Shirani J, Haftbaradaran A, Go D, Schiavone W. Streptococcal pharyngitis-associated myocarditis mimicking acute STEMI. JACC Cardiovasc Imaging 2010;3(8):892–893.
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hest pain with electrocardiographic ST elevation is managed today with coronary arteriography at a hospital capable of percutaneous coronary intervention (PCI). When no culprit coronary stenosis is found, the angiographic catheter is removed, and it is often the responsibility of another physician to determine the cause of the pain and electrocardiographic changes. Pericarditis is often diagnosed, but it does not explain the elevation in cardiac biomarkers. Treatment with a nonsteroidal antiinflammatory drug with or without colchicine might offer benefit, but in some cases it is not enough. Days of insufficient treatment might pass before the evolution of electrocardiographic changes looks more like myocarditis than pericarditis. In this issue of BUMC Proceedings, Aguirre and coworkers (1) present a case of streptococcal pharyngitis–associated myocarditis. They describe the presentation in a 43-year-old man and a logical sequence of tests used to diagnose acute myocarditis and its association with group A streptococcal pharyngitis. They deserve special commendation for their tabular collation of the published literature of this disease, including this case. There are fewer than 50 cases of streptococcal pharyngitis– associated myocarditis in the medical literature. Yet, annually in the US, 11 million patients present to an emergency department or ambulatory care setting with sore throat, and group A streptococcus is responsible for 5% to 15% of sore throats in adults and 20% to 30% in children (2, 3). The incidence of streptococcal pharyngitis–associated myocarditis might be larger than is recognized. Treatment with penicillin provides clinical improvement in 2 to 3 days and improvement in left ventricular function (4). Delayed diagnosis or failure to diagnose can result in persistent left ventricular dysfunction and recurrence. Is chronic antibiotic suppression of group A streptococcus needed, as is used to prevent recurrent acute rheumatic fever? Is it necessary only when there is persistent exposure to unhygienic carriers like schoolchildren? When is tonsillectomy needed? A high index of suspicion for streptococcal pharyngitis– associated myocarditis is necessary when a young patient,
Proc (Bayl Univ Med Cent) 2015;28(2):191
especially male, with no risk factors for coronary artery disease presents to the emergency department with chest pain, electrocardiographic ST elevation, and elevated cardiac biomarkers and has no culprit coronary stenosis. The next questions must be about close recent exposure to someone with streptococcal pharyngitis and/or a sore throat in the last week. Cultures and serologic testing for streptococcal infection can detect chronic asymptomatic exposure. What would foster recognition of streptococcal pharyngitis– associated myocarditis? A catchy name might help. I propose an additional dictionary definition of the word spam, with all capital letters: SPAM (noun) 1. Trademark for spiced ham (1937) 2. Unsolicited or undesired electronic message (1990s) 3. Streptococcal pharyngitis–associated myocarditis (2010) SPAM might be included in the guidelines for the management of STEMI. When it is diagnosed in greater numbers, controlled trials can be designed to answer these questions about the benefits of chronic antibiotic suppression and of tonsillectomy. —William A. Schiavone, DO Heart and Vascular Institute Cleveland Clinic E-mail: [email protected] 1.
2. 3.
4.
Aguirre JL, Jurado M, Porres-Aguilar M, Olivas-Chacon C, Porres-Muñoz M, Mukherjee D, Taveras J. Acute nonrheumatic streptococcal myocarditis resembling ST-elevation acute myocardial infarction in a young patient. Proc (Bayl Univ Med Cent) 2015;28(2):188–190. Hing E, Cherry DK, Woodwell DA. National ambulatory medical care survey: 2003 summary. Adv Data 2005;365:1–48. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55(10):e86–e102. Mokabberi R, Shirani J, Haftbaradaran A, Go D, Schiavone W. Streptococcal pharyngitis-associated myocarditis mimicking acute STEMI. JACC Cardiovasc Imaging 2010;3(8):892–893.
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