Myocarditis (Case 48)

Chapter 90 Myocarditis (Case 48)



Aaron D. Kessel, MD




Case


A 4-year-old child with respiratory distress, tachypnea, and tachycardia




Differential Diagnosis













Pneumonia Bronchiolitis/dehydration/viral illness Myocarditis/dilated cardiomyopathy
Pericarditis Pneumothorax Asthma


Speaking Intelligently


When evaluating a patient in respiratory distress, I first consider the ABCs: airway, breathing, and circulation. When I suspect a cardiac etiology, I obtain a chest radiograph and an electrocardiogram (ECG). I feel it is prudent to consult a cardiologist quickly, because the management of a cardiac illness can be complicated and beyond the scope of many practitioners. It is important to closely monitor the hemodynamic status because patients with myocarditis may have a rapidly changing course and immediate adjustments in medical care are required. Transfer to a tertiary care facility with intensive care specialists and cardiologists should occur immediately after stabilization.



Patient Care



Clinical Thinking



• Address the ABCs before further intervention.

• There are many possible causes of tachypnea and tachycardia. Consider the most likely for age and history first.


History



• How long has the patient had the current symptoms?

• Has the child had fever, symptoms of a viral illness, or any sick contacts?

• Does the patient have any other medical problems? Has the patient suffered from a similar episode in the past?

• Has the child had other symptoms during the same time period?

• Do these symptoms affect daily activities? Has the patient had a normal energy level since the symptoms began?

• Has the patient been gaining weight appropriately?


Physical Examination



• Vital signs: Note tachypnea and/or tachycardia. The patient may have decreased oxygen saturation secondary to pulmonary edema. If critically ill, these may be associated with hypotension. The patient may also have a fever.

• There may be respiratory distress with tachypnea, retractions, and nasal flaring. Note crackles and decreased breath sounds at the lung bases.

• Cardiac examination may reveal:
• Tachycardia (regular or irregular rhythm)

• An S3/S4 gallop from volume overload and cardiac wall impairment

• A friction rub

• A new-onset systolic murmur from mitral or tricuspid insufficiency

• Abdominal examination may reveal hepatomegaly secondary to congestive heart failure.

• Extremity examination may reveal pallor, increased time of capillary refill, poor pulses, cool extremities, and edema.


Tests for Consideration



• Complete blood count (CBC): White blood cells (WBCs) when infection is suspected; hemoglobin to assess oxygen-carrying capacity $110

• Electrolyte levels: To examine metabolic and renal function. Sodium may be decreased and blood urea nitrogen (BUN) increased with fluid overload in congestive heart failure (CHF) $115

• Liver function tests: May be elevated with hepatic congestion in right-sided heart failure $65

• Arterial blood gas (ABG), including lactate, demonstrate ventilatory status and acid-base status. Elevated lactate level is a sign of anaerobic metabolism and may indicate poor perfusion. $45

• Cardiac enzyme levels: Troponin I/T and creatine kinase, myocardial (CK-MB): Elevation reveals cardiac ischemia. $75

• Blood culture $55

• Viral culture $55

• Viral titers: Adenovirus, echovirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), human immunodeficiency virus (HIV) $50-$250 per test

• Nonspecific indicators of systemic inflammation:
• C-Reactive protein: $65

• Erythrocyte sedimentation rate $65


Imaging Considerations


→ Chest radiograph: To evaluate lung fields, pulmonary vasculature, and heart size. $75


→ ECG: Often shows sinus tachycardia, low voltages, and inverted T waves. May demonstrate arrhythmias, including ventricular tachycardia (VT), supraventricular tachycardia (SVT), premature atrial complexes (PACs) and premature ventricular contractions (PVCs). $150


→ Echocardiogram: To evaluate left ventricular function and size, and atrioventricular (AV) valve function. $325

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Myocarditis (Case 48)

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