Myocarditis (peds): Difference between revisions
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''This page is for <u>pediatric</u> patients; for adult patients see [[myocarditis]].''
{{Peds top}} [[myocarditis]]
==Background==
==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 [[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]]
*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>
**[[Shortness of breath (peds)|Shortness of breath]]
**[[Fever]]
**[[URI]] symptoms
**[[Vomiting]] or [[abdominal pain (peds)|abdominal pain]]
**Exercise intolerance
**Poor feeding
**Hypoperfusion (e.g. [[syncope]] or [[seizure (peds)|seizure]]
**+/- [[chest pain]], [[palpitations]]<ref>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</ref>
*Exam findings include<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>
**[[Tachycardia]]
***Consider myocarditis in any child who remains persistently tachycardic despite appropriate treatment for fever, dehydration, etc.
***Only present in 46-58% of cases in 3 large reviews<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><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><ref>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.</ref>, so ''lack'' of tachycardia does ''not'' rule out myocarditis
**[[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)
**[[Altered mental status (peds)|Lethargy]]


==Differential Diagnosis==
==Differential Diagnosis==
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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]]
**[[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>
***Low voltage
***Axis deviation
***ST or [[T wave changes]]
***[[AV blocks]] or conduction delays
***[[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]]
**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>
**Cardiomegaly
**[[Pulmonary edema]]
**[[Pleural effusions]]
*[[Echocardiography]]
**Unnecessary if both CXR and ECG are normal, unless you have high clinical suspicion


==Management==
==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==
==Disposition==
 
*Admit, often to ICU


==See Also==
==See Also==
 
*[[Myocarditis]]


==External Links==
==External Links==
 
*https://pedemmorsels.com/myocarditis/


==References==
==References==
<references/>
<references/>
[[Category:Pediatrics]]
[[Category:Cardiology]]

Revision as of 04:22, 16 May 2020

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
  • Typically viral but often no pathogen identified. Other causes include bacterial, toxins, and autoimmune causes

Clinical Features

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

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

  1. ↑ 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.
  2. ↑ 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
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ Eisenberg MA1, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children
  8. ↑ 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
  9. ↑ 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.
  10. ↑ Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24:495
  11. ↑ 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.
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