Myocarditis (peds): Difference between revisions
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==Background== | ==Background== | ||
*Rare but potentially fatal | *Rare but potentially fatal | ||
*Most common cause of heart failure in previously healthy children | *Most common cause of heart failure in previously healthy children, also one of the etiologies for unexpected sudden cardiac death in infants | ||
*Inflammation of myocardium | *Inflammation of myocardium | ||
**Can lead to dilated [[cardiomyopathy]] | **Can lead to dilated [[cardiomyopathy]] | ||
*Typically [[viruses|viral]] but often no pathogen identified | *Typically [[viruses|viral]] but often no pathogen identified. Other causes include bacterial, toxins, and autoimmune causes | ||
==Clinical Features== | ==Clinical Features== | ||
*Symptoms often initially nonspecific in prodromal stage, may be misdiagnosed as [[URI]], [[pneumonia]], [[acute gastroenteritis (peds)|gastroenteritis]], [[asthma]] | *Symptoms often initially nonspecific in prodromal stage, may be misdiagnosed as [[URI]], [[pneumonia]], [[acute gastroenteritis (peds)|gastroenteritis]], [[asthma]] | ||
*Prodrome typically lasts ~ | *Prodrome typically lasts ~1-2 weeks | ||
*Most common presenting symptoms include <ref>Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.</ref> | *Most common presenting symptoms include <ref>Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.</ref> | ||
**[[Shortness of breath (peds)|Shortness of breath]] | **[[Shortness of breath (peds)|Shortness of breath]] | ||
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**[[URI]] symptoms | **[[URI]] symptoms | ||
**[[Vomiting]] or [[abdominal pain (peds)|abdominal pain]] | **[[Vomiting]] or [[abdominal pain (peds)|abdominal pain]] | ||
**Exercise intolerance | |||
**Poor feeding | **Poor feeding | ||
**Hypoperfusion (e.g. [[syncope]] or [[seizure (peds)|seizure]] | **Hypoperfusion (e.g. [[syncope]] or [[seizure (peds)|seizure]] | ||
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**[[Fever]] | **[[Fever]] | ||
**[[Respiratory distress]], tachypnea | **[[Respiratory distress]], tachypnea | ||
***Have a high index of suspicion on the child that has worsening respiratory status after receiving fluids | |||
**[[Hepatomegaly]] | **[[Hepatomegaly]] | ||
**Signs of poor perfusion (e.g. decreased cap refill, mottled skin) | **Signs of poor perfusion (e.g. decreased cap refill, mottled skin) | ||
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==Evaluation== | ==Evaluation== | ||
*Blood work | |||
**Elevated [[troponin]]<ref>Eisenberg MA1, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children</ref> | |||
**Elevated BNP<ref>Koulouri S, Acherman RJ, Wong PC, et al. Utility of B-type natriuretic peptide in differentiating congestive heart failure from lung disease in pediatric patients with respiratory distress. Pediatr Cardiol 2004; 25:341</ref> | |||
**Markers of inflammation such as ESR and CRP may be elevated, but are nonspecific | |||
**Elevated [[LFTs]] | |||
**Blood gas to evaluate for systemic perfusion | |||
*[[ECG]] | *[[ECG]] | ||
**[[Sinus tachycardia]] is most common abnormality | **[[Sinus tachycardia]] is most common abnormality | ||
**Other abnormalities includes<ref>Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.</ref> | **Other abnormalities includes<ref>Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.</ref> | ||
** | ***Low voltage | ||
**Axis deviation | ***Axis deviation | ||
**ST or [[T wave changes]] | ***ST or [[T wave changes]] | ||
**[[AV blocks]] | ***[[AV blocks]] or conduction delays | ||
**[[myocardial ischemia|Ischemic]] patterns | ***[[myocardial ischemia|Ischemic]] patterns | ||
***SVT or ventricular arrhythmias<ref>Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24:495</ref> | |||
*[[CXR]] | *[[CXR]] | ||
**Not sensitive, but often abnormal<ref>Durani Y1, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009 Oct;27(8):942-7.</ref> | **Not sensitive, but often abnormal<ref>Durani Y1, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009 Oct;27(8):942-7.</ref> | ||
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*[[Echocardiography]] | *[[Echocardiography]] | ||
**Unnecessary if both CXR and ECG are normal, unless you have high clinical suspicion | **Unnecessary if both CXR and ECG are normal, unless you have high clinical suspicion | ||
==Management== | ==Management== | ||
*Management tailored to severity of disease | *Management tailored to severity of disease | ||
*Maintain euvolemia, [[ | *Maintain euvolemia, consider [[furosemide]] as needed | ||
*If cardiac function significantly depressed, consider [[ | *If cardiac function significantly depressed, consider [[epinephrine]] or [[dopamine]] | ||
*Consider afterload reduction with [[nitroprusside]] if normotensive | *Consider afterload reduction with [[nitroprusside]] if normotensive | ||
*Treat [[arrhythmias]] | *Treat [[arrhythmias]] | ||
**Unstable - cardioversion at 0.5-1 J/kg (max 2J/kg) | |||
**Stable - consider lidocaine or amiodarone | |||
**Avoid digoxin due to risk of precipitating more significant dysrhythmias in irritable myocardium | **Avoid digoxin due to risk of precipitating more significant dysrhythmias in irritable myocardium | ||
*Admit to Pediatric ICU, preferably with ECMO capabilities | |||
==Disposition== | ==Disposition== | ||
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==External Links== | ==External Links== | ||
*https://pedemmorsels.com/myocarditis/ | *https://pedemmorsels.com/myocarditis/ | ||
*[https://emergencymedicinecases.com/pediatric-respiratory-failure/ EMCases - Pediatric Myocarditis] | |||
==References== | ==References== | ||
Latest revision as of 02:48, 2 July 2021
This page is for pediatric patients. For adult patients, see: myocarditis
Background
- Rare but potentially fatal
- Most common cause of heart failure in previously healthy children, also one of the etiologies for unexpected sudden cardiac death in infants
- Inflammation of myocardium
- Can lead to dilated cardiomyopathy
- Typically viral but often no pathogen identified. Other causes include bacterial, toxins, and autoimmune causes
Clinical Features
- Symptoms often initially nonspecific in prodromal stage, may be misdiagnosed as URI, pneumonia, gastroenteritis, asthma
- Prodrome typically lasts ~1-2 weeks
- Most common presenting symptoms include [1]
- Shortness of breath
- Fever
- URI symptoms
- Vomiting or abdominal pain
- Exercise intolerance
- Poor feeding
- Hypoperfusion (e.g. syncope or seizure
- +/- chest pain, palpitations[2]
- Exam findings include[3]
- Tachycardia
- Fever
- Respiratory distress, tachypnea
- Have a high index of suspicion on the child that has worsening respiratory status after receiving fluids
- Hepatomegaly
- Signs of poor perfusion (e.g. decreased cap refill, mottled skin)
- Lethargy
Differential Diagnosis
Pediatric Shortness of Breath
Pulmonary/airway
- Airway obstruction
- Structural
- Infectious
- Other
Cardiac
- Congenital heart disease
- Vascular ring
- Cardiac tamponade
- Congestive Heart Failure (peds)
- Myocarditis (peds)
Other diseases with abnormal respiration
- Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
- Brief resolved unexplained event
- Anemia
- Abdominal distension (e.g. SBO, liver failure
- Neonatal abstinence syndrome
- Decreased perfusion states
- Metabolic acidosis
- CO Poisoning
- Diaphragm injury
- Renal Failure
- Electrolyte abnormalities
- Organophosphate toxicity
- Tick paralysis
- Fever (Peds)
- Panic attack
- Porphyria
Evaluation
- Blood work
- ECG
- Sinus tachycardia is most common abnormality
- Other abnormalities includes[9]
- Low voltage
- Axis deviation
- ST or T wave changes
- AV blocks or conduction delays
- Ischemic patterns
- SVT or ventricular arrhythmias[10]
- CXR
- Not sensitive, but often abnormal[11]
- Cardiomegaly
- Pulmonary edema
- Pleural effusions
- Echocardiography
- Unnecessary if both CXR and ECG are normal, unless you have high clinical suspicion
Management
- Management tailored to severity of disease
- Maintain euvolemia, consider furosemide as needed
- If cardiac function significantly depressed, consider epinephrine or dopamine
- Consider afterload reduction with nitroprusside if normotensive
- Treat arrhythmias
- Unstable - cardioversion at 0.5-1 J/kg (max 2J/kg)
- Stable - consider lidocaine or amiodarone
- Avoid digoxin due to risk of precipitating more significant dysrhythmias in irritable myocardium
- Admit to Pediatric ICU, preferably with ECMO capabilities
Disposition
- Admit, often to ICU
See Also
External Links
References
- ↑ Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.
- ↑ Dancea AB. Myocarditis in infants and children: A review for the paediatrician. Paediatr Child Health. 2001;6(8):543–545. doi:10.1093/pch/6.8.543
- ↑ Durani Y1, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009 Oct;27(8):942-7.
- ↑ Durani Y1, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009 Oct;27(8):942-7.
- ↑ Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.
- ↑ Shu-Ling C1, Bautista D, Kit CC, Su-Yin AA. Diagnostic evaluation of pediatric myocarditis in the emergency department: a 10-year case series in the Asian population. Pediatr Emerg Care. 2013 Mar;29(3):346-51.
- ↑ Eisenberg MA1, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children
- ↑ Koulouri S, Acherman RJ, Wong PC, et al. Utility of B-type natriuretic peptide in differentiating congestive heart failure from lung disease in pediatric patients with respiratory distress. Pediatr Cardiol 2004; 25:341
- ↑ Freedman SB1, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec;120(6):1278-85.
- ↑ Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24:495
- ↑ Durani Y1, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009 Oct;27(8):942-7.