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Myocarditis and Dilated Cardiomyopathy in Athletes:Diagnosis, Management, and Recommendationsfor Sport ActivityCristina Basso, MD, PhD a, * , Elisa Carturan, BSc, PhD a ,Domenico Corrado, MD, PhD b ,Gaetano Thiene, MD, FRCP Hon aa Department of Medical-Diagnostic Sciences and Special Therapies, University of Padua Medical School,Via A. Gabelli 61, 35121 Padova, Italyb Department of Cardio-Thoracic and Vascular Sciences, University of Padua Medical School, Via N. Giustiniani 2,35128 Padova, ItalyAccording to the World Health Organization/International Society and Federation of Cardiol-ogy Task Force on the Def i nition and Classif i ca-tion of Cardiomyopathies, ‘‘myocarditis is aninf l ammatory heart muscle disease associatedwith cardiac dysfunction and it is diagnosed byestablished histological, immunological, and im-munohistochemical criteria.’’ It is characterizedby the histologic evidence of inf l ammatory in-f i ltrates associated with myocyte degeneration andnecrosis of nonischemic origin [1]. Currently, it islisted among specif i c cardiomyopathies and, assuch, called inf l ammatory cardiomyopathy [2].Myocarditis may be classif i ed based on etio-logic (infective or noninfective myocarditis) andhistologic criteria (lymphocytic, eosinophilic,polymorphous, granulomatous, giant cell).Among noninfective forms of myocarditis, thehypersensitivity type is the most common form ofacute drug-related myocardial injury. The histo-pathology is characterized by a dif f use inf l amma-tory inf i ltrate rich in eosinophils. In contrast,toxic myocarditis consists of myocyte necrosisassociated with a mixed inf l ammatory inf i ltrateof polymorphonuclear and mononuclear cells.Several medications and toxins may exert a directcytotoxic ef f ect on the heart (eg, lithium, doxoru-bicin, cocaine, catecholamines, acetaminophen),as well as environmental toxins (lead, arsenic,alcohol, carbon monoxide) or wasp, scorpion, andspider stings; however, infectious agents, such asviruses, are the most common cause of myocar-ditis. Infectious causes most commonly includeviral (coxsackievirus, adenovirus, parvovirus, her-pes virus, HIV), bacterial (diphtheria, meningo-coccus, psittacosis, streptococcus), rickettsial(typhus, Rocky Mountain spotted fever), fungal(aspergillosis, candidiasis), and parasitic agents(Chagas disease, toxoplasmosis) [3]. Acute myo-carditis, especially viral forms, can be resolvedwithout sequela; however, progression in thechronic form (ie, dilated cardio myopathy[DCM]) is not a rare event.The diagnosis of myocarditis relies on estab-lished histopathologic, histochemical, or molecu-lar criteria but is clinically challenging. Theclinical presentation of myocarditis is highly vari-able and includes unexplained congestive heartfailure (eg, exertional dyspnea, fatigue) or cardio-genic shock, chest pain with myocardial enzymerelease mimicking myocardial infarction, palpita-tions, syncope, or even sudden death. The clinicalevaluation of patients with suspected myocarditisincludes a personal and family history, physicalexamination, 12-lead ECG, and echocardiogra-phy. Additional testing (such as 24-hour ECGThis work was supported by the Veneto Region,Venice, Italy; Cariparo Foundation, Pedove, Italy;Ministry of Health, Rome, Italy.* Corresponding author.E-mail address: cristina.basso@unipd.it (C. Basso).0733-8651/07/$ - see front matter ? 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.ccl.2007.08.008 cardiology.theclinics.comCardiol Clin 25 (2007) 423–429