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Morning Report
7/15/2015
Sydney Ryan PGY3

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HPI

7yr old male with 2-3 days of sore throat

Temperature up to 102

New onset neck pain

Mom endorses mild congestion and cough for the past

several days and decreased oral intake for the past
day.

He was transferred from an urgent care to the PCH ED

for concerning progressive neck pain.

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History Continued

Birth History: Term male without complications.

Family History: Maternal history of stage 4 colon cancer

with metastasis to liver. No sick contacts. No h/o MRSA
or recurrent skin infection.

Social History: Lives with mom, dad and one healthy

sibling. No cats or dogs in the home.

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History Continued

No Hospitalizations

T&A at 4yr old for recurrent strep infections

PMH: No chronic illness/use of medication

Allergies: NKDA

Medications: none regularly

Immunizations: Up to date

ROS: +neck pain, sore throat, fever, decreased PO intake,

cough and congestion. Negative for rash, diarrhea,
vomiting, change in conjunctiva.

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ED Hospital course

Admitted to inpatient team:

Day one: found to have neck mass. CT showed

lymphadenitis without abscess formation. Started on
Clindamycin and Ceftriaxone. ENT was involved/consulted.

Overnight: Resident called to bedside for low urine output,

tachycardia and fever. Also noted to be vomiting with
abdominal pain.

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Physical Exam

Temp: 38.0 RR:52 HR: 152 BP: 86/40 Oxygen: 85-92% on room air

General: in moderate distress

HEENT: normal sclera, no nasal drainage, left sided submandibular

mass that was tender to palpation. Pain with neck movement.

CV: tachycardic, heart sounds were difficult to assess, capillary

refill 3seconds, strong pulses peripherally

RESP: Tachypnic, subcostal retractions, no wheezes

Abd: soft, nontender, nondistended. BS present

Skin: blanching macular rash on palms and soles

Neuro: CN II-XII intact, EOMI, pupils equal and responsive to light.

No focal deficits.

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Case
This is a 7year old male with 34days of neck pain, fever and viral
symptoms in the setting of
lymphadenitis, who acutely
developed tachycardia, respiratory
distress, vomiting and abdominal
pain.

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Differential Diagnosis

GI

Gastritis

Dehydration

Obstruction

Intussusception

Infectious

Neuro

Meningitis

Encephalopathy

Cardiac

Arrhythmia

Cardiac Tampanode

Pneumonia

Endocarditis

Abscess formation

Pericarditis

Bronchiolitis

Fever

Myocarditis

Lemierres syndrome (jugular venous

thrombophlebitis)

EBV

Kawasaki Disease

Progression of viral illness

Septic shock

Other

Chemical exposure

Steven-Johnsons syndrome/drug
erruption

Pulm/airway

Interstitial fibrosis

Sarcoidosis

Airway obstruction from mass

Lupus

Pulmonary edema

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Laboratory Results

Troponin: 3.42

CKMB 15

BNP 1400

CBC: 12.2 WBC, 13.9 hgb, 290 plts (23%bands,

58%neutrophil, 13%lymphocytes)

CMP: normal

VRP: Rhino +

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Other Data

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Other Data

ECHO results:

Mildly decrease LV function, normal size

Mild Tricuspid regurgitation and mitral valve regurgitation,

Mildly decrease PV function, normal size

Small pericardial effusion

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Other Data

Sinus tachycardia, diffuse ST abnormality and prolonged QTc

Diagnosis: Likely Viral

Myocarditis

Myocarditis
Pathophysiology: cellular damagemyocardial
dysfunctionheart failure

Myocarditis- Etiology

Viral: Coxsackievirus types A and B, Adenovirus (type 2

and 5),
Hepatitis C, Parvovirus B19, EBV and CMV,
Herpes virus, Echovirus, HIV, Influenza, parainfluenza,
measeles, rubella

Bacterial: Staph, Strep, Tuluremia, Brucella, Heamophilus,

meningococcal, TB, legionella, and others

Infectious: Rickettsial, Protozoal, Helminthic, etc

Cardiotoxins: alcohol, cocaine, arsenic, carbon monoxide,

and heavy metals

Systemic disease: sarcoidosis, IBD, Celiac disease,

Kawasaki disease, Lupus

Hypersensitivity reactions: insect bites, snake bites,

diuretics, antibiotics

Myocarditis-Presentation

Prodrome several days prior: fever, malaise, myalgias

Acute presentation (heart failure): rest, exercise intolerance,

syncope, tachypnea, tachycardia, and hepatomegaly

Others: respiratory distress or gastrointestinal symptoms

(anorexia, abdominal pain, and vomiting), arrhythmias, and
heart block

Fulminant myocarditis (poor output): hypotension, poor

pulses and decreased perfusion, acidosis, and
hepatomegaly, which may progress to cardiovascular
collapse

ON EXAM: S4 gallup, murmurs,

Myocarditis
Initial Testing:

ECG: abnormal, although changes are neither specific nor

sensitive. Changes include ST segment and inverted T
waces, abnormal axis, ventricular/atrial enlargement and
decreased voltage

BNP: Non-specific

Troponin and CK-MB for a more acute presentation (vs

dilated cardiomyaopathy)

Chest xray: Abnormal in about half that patients with

cardiomegaly and pulmonary congestion

Blood gas may reflect poor perfusion with metabolic

acidosis

Other: MRI with contrast (inflammation), Biopsy

Myocarditis
Three Phases:

Viral Infection phase: Prodome of several days: fever,

malaise, mylagias, GI symptoms

Autoimmune/Inflammatory phase: T cell and cytokine

activationheart failure

Dilated Cardiomyopathy phase: (small subset)

Myocarditis

Treatment:

Due to the high risk of arrythmias, they should be in

the PICU

Initial supportive treatment consists of exogenous

oxygen delivery, careful fluid resuscitation, nutritional
support, and possible blood transfusion to increase
oxygen carrying capacity. In some cases, more
significant supportive care (eg, intravenous inotropic
support, mechanical ventilation, and mechanical
circulatory support) may be needed during the acute
illness prior to myocardial recovery, and in other cases,
patients will progress to end-stage dilated
cardiomyopathy and require cardiac transplantation for
long-term survival.

Myocarditis
Treatment (cont)

Diuretics

Prevention of circulatory collapse: Milronone, Dopamine,

dobutamine

Other considerations (no obvious benefit in studies): antiarrythmics, IVIG, anti-virals, corticosteroids

Myocarditis
Prognosis:

The majority of patients eventually recover completely

Some require heart transplant (dilated cardiomyopathy)

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References

Catherine K Allan, MD, et al. UpToDate: Clinical

manifestations and diagnosis of myocarditis in children.
Mar 13, 2014.

Catherine K Allan, MD, et al. UpToDate: Treatment and

prognosis of myocarditis in children. March 13, 2014.

Edwin Rodriguez-Cruz, MD. Emedicine: Pediatric Viral

Myocarditis. Aug 29, 2013