Myocarditis (peds)

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]
  • Exam findings include[3]
    • 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[4][5][6], 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)
    • Lethargy

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

  • Blood work
    • Elevated troponin[7]
    • Elevated BNP[8]
    • Markers of inflammation such as ESR and CRP may be elevated, but are nonspecific
    • Elevated LFTs
    • Blood gas to evaluate for systemic perfusion
  • ECG
  • CXR
  • 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

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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