Richardson P J
Heart Vessels Suppl. 1985;1:97-100. doi: 10.1007/BF02072371.
The diagnosis of myocarditis is discussed with reference to endomyocardial biopsy and the possible relation of dilated cardiomyopathy to myocarditis is explored. The various degrees of immune damage to the myocardium produced by myocarditis are reviewed, and evidence for altered immunity in dilated cardiomyopathy is assessed. The rationale for immunosuppressive therapy is surveyed. Both clinical and experimental data suggest that viral myocarditis is biphasic. The initial phase is infective with myocytolysis, lymphocytic infiltration, and a humoral immune response. The second phase is associated with a persistent antigen-antibody reaction between the virus and the myocardium. Myocarditis may be acute with lymphocytic infiltration and myocytolysis; persistent active, with continuing changes including widening of the interstitium and fibrosis; healing, with persistent inflammatory cell exudate but no myocyte necrosis; and healed, with the absence of necrosis and of inflammatory cell infiltrates but widening of the interstitium and fibrosis. This state is indistinguishable from dilated cardiomyopathy. The selection of patients for treatment and the regimens of treatment are discussed. Acute myocarditis or persistent active myocarditis are indications for therapy with steroids and the immunosuppressive agent azathioprine. Benefit is unlikely when myocarditis is healed. Lymphocytic inflammatory cell infiltration alone is not sufficient indication for such therapy, because such infiltration may be found in dilated cardiomyopathy and also in toxic myocarditis due to drugs. Results of immunosuppressive therapy for acute and active myocarditis are encouraging, but a prospective randomized study is needed.
本文讨论了心肌炎的诊断，并参考心内膜心肌活检进行探讨，同时探究了扩张型心肌病与心肌炎之间可能存在的关系。回顾了心肌炎对心肌造成的不同程度的免疫损伤，并评估了扩张型心肌病中免疫改变的证据。审视了免疫抑制治疗的基本原理。临床和实验数据均表明病毒性心肌炎具有双相性。初始阶段具有感染性，伴有心肌细胞溶解、淋巴细胞浸润和体液免疫反应。第二阶段与病毒和心肌之间持续的抗原抗体反应相关。心肌炎可能为急性，伴有淋巴细胞浸润和心肌细胞溶解；持续性活动型，伴有持续变化，包括间质增宽和纤维化；愈合期，伴有持续性炎性细胞渗出但无心肌细胞坏死；已愈合，无坏死和炎性细胞浸润，但间质增宽和纤维化。这种状态与扩张型心肌病难以区分。文中讨论了治疗患者的选择和治疗方案。急性心肌炎或持续性活动型心肌炎是使用类固醇和免疫抑制剂硫唑嘌呤进行治疗的指征。心肌炎已愈合时不太可能获益。仅淋巴细胞炎性细胞浸润不足以作为此类治疗的指征，因为在扩张型心肌病以及药物所致的中毒性心肌炎中也可能发现这种浸润。急性和活动型心肌炎免疫抑制治疗的结果令人鼓舞，但仍需要进行前瞻性随机研究。
