From the Guidelines
Myocarditis in leptospirosis is a serious condition that can present with various ECG findings, and the most recent guidelines recommend a comprehensive approach to diagnosis and management, including the use of cardiac magnetic resonance (CMR) imaging and careful consideration of competitive sports participation 1.
ECG Findings
The ECG findings in myocarditis due to leptospirosis can include:
- Sinus tachycardia
- Atrial fibrillation
- Non-specific ST-segment and T-wave changes
- First-degree atrioventricular block
- Prolonged QT interval
- Complete heart block
- Bundle branch blocks
- Ventricular arrhythmias These changes reflect the inflammatory process affecting the myocardium as Leptospira bacteria trigger an immune response, causing direct myocardial damage and vasculitis.
Diagnosis and Management
When managing suspected leptospirosis myocarditis, it is essential to:
- Obtain serial ECGs to monitor for evolving changes, particularly conduction abnormalities that might require temporary pacing
- Use CMR imaging to evaluate for myocardial scar and edema
- Assess biomarkers indicating inflammation and nonischemic myocardial injury
- Provide appropriate antibiotic therapy, such as penicillin G or ceftriaxone, alongside supportive care for cardiac manifestations
- Consider cardiac monitoring in an ICU setting for severe cases, as myocarditis can lead to heart failure or life-threatening arrhythmias
Competitive Sports Participation
For competitive athletes with suspected myocarditis, the guidelines recommend:
- Withholding participation in competitive sports until symptoms and active inflammation or edema have resolved
- Using CMR imaging to evaluate for myocardial scar and edema
- Assessing LV function and resolving any clinically relevant arrhythmias before considering resumption of competitive sports participation 1 It is crucial to prioritize the athlete's safety and well-being, and to carefully consider the risks and benefits of competitive sports participation in the context of myocarditis.
From the Research
Myocarditis in Leptospirosis
- Myocarditis is a known complication of severe leptospirosis, although it may be overlooked due to non-specific clinical findings and co-existing multi-organ dysfunction 2.
- Studies have shown that myocardial inflammation often complicates leptospirosis, and cardiac involvement may not differ from that of sepsis-associated myocarditis 3.
ECG Findings
- ECG abnormalities are common in patients with leptospirosis, with non-specific ventricular repolarization disturbances being the most common finding 4.
- Other recorded ECG abnormalities include sinus tachycardia, right branch conduction disturbances, low voltage of the QRS complex, supraventricular and ventricular extrasystoles, intraventricular conduction disturbances, atrioventricular block, and atrial fibrillation 4.
- ST-segment elevation and elevated troponin are independent predictors of reduced left ventricular ejection fraction in leptospirosis 3.
- Atrial fibrillation, atrial and ventricular tachycardia, and new-onset cardiomyopathy have also been reported in patients with leptospirosis-induced myocarditis 5.
- Pericarditis has also been described as a cardiac manifestation of acute leptospirosis, with ST segment elevation in the electrocardiogram 6.
Cardiac Involvement
- Cardiac involvement in leptospirosis appears to be similar to that of sepsis syndrome, with myocardial systolic dysfunction being common 3.
- Myopericarditis has been identified in some patients with leptospirosis, and cardiac biomarker evaluation has shown elevated troponin levels 2, 3.
- Left ventricular dysfunction is rare, but can occur in patients with fulminant leptospirosis infection 5.