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Myocarditis Presenting Symptoms American Journal of Emergency Medicine (2009) 27, 942–947 www.elsevier.com/locate/ajem Original Contribution Pediatric myocarditis: presenting clinical characteristics Yamini Durani MD a,⁎, Matthew Egan MD b, Jeanne Baffa MD c, Steven M. Selbst MD a, Alan L. Nager MD d,e aDivision of Emergency Medicine, Department of Pediatrics, Alfred I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, DE 19899, USA bDivision of Pediatric Cardiology, Columbus Children's Hospital, Columbus, OH 43205, USA cDivision of Pediatric Cardiology, Alfred I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, DE 19899, USA dDivision of Emergency Medicine and Transport Medicine, Department of Pediatrics, Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA eKeck School of Medicine of the University of Southern California, Los Angeles, CA 90089, USA Received 23 June 2008; revised 23 July 2008; accepted 24 July 2008 Abstract Objective: The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis. Methods: A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes. Results: A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty- three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results. Conclusions: These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses. © 2009 Elsevier Inc. All rights reserved. 1. Background Myocarditis, the inflammation of the muscular walls of This article was presented, in part, at the Pediatric Academic Societies Meeting in San Francisco, April 2006. the heart, remains a diagnostic challenge in the clinical ⁎ Corresponding author. Tel.: +1 302 651 4296; fax: +1 302 651 4227. setting because of the variability of presentations in the E-mail address: [email protected] (Y. Durani). pediatric population. It is nonetheless an important 0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.07.032 Pediatric myocarditis: presenting clinical characteristics 943 diagnosis, as it is the most common etiology of heart failure The institutional review boards of both participating in previously healthy pediatric patients [1]. The initial hospitals approved the study. diagnosis of myocarditis is highly dependent upon clinical Children up to 18 years old who were identified as having suspicion because diagnosis based on endomyocardial myocarditis or DCM based on the International Classifica- biopsy has many inherent risks and is therefore not tion of Diseases, Ninth Revision, codes were eligible for the performed routinely. Unless a high index of suspicion is study. Only patients diagnosed with DCM secondary to acute maintained, acute myocarditis may easily be missed; and the myocarditis were included in the study. Patients with DCM diagnosis may only be obvious in cases when fulminant secondary to other causes such as cardiotoxic drugs, inborn disease is present. errors of metabolism, malformation syndromes, neuromus- Patients often present with prodromal symptoms that cular disorders, or other familial syndromes were excluded. are not recognized to be associated with myocarditis In all cases, the final diagnosis was based upon expert initially. In a study of 90 patients younger than 16 years opinion of a pediatric cardiologist. who died suddenly and unexpectedly, myocarditis was A standardized data collection form was used to abstract found to be a major cause of death in 17%; and 60% of data from hospital medical records. Data were abstracted by these patients had prodromal symptoms [2]. In another 3 investigators. Data collected included demographics, study by Freedman et al of 14 patients seen by a clinical history, physical examination, and results of physician before the diagnosis of myocarditis, 57% were laboratory evaluation. originally diagnosed as having pneumonia or asthma. In The clinical history and physical examination data were addition, 32% of patients presented with respiratory obtained from the first documented encounter at our symptoms, 29% had cardiac symptoms, and 6% had institutions' EDs. If patients were transferred to our facilities gastrointestinal symptoms. from an outside institution and did not have an ED Previous research has shown that acute myocarditis may evaluation, the historical and clinical data were collected progress to dilated cardiomyopathy (DCM). This occurs as from intensive care unit records or the referring hospital's myocytes are injured by both direct viral injury and by the initial medical evaluation. inflammatory response of the host via the effects of The presence or absence of the following clinical features cytokines, autoantibodies, macrophages, natural killer cells, was collected: fever, diaphoresis, lethargy, fatigue, change in and lymphocytic cells [3,4]. Although DCM may result from exercise tolerance, syncope, seizures, difficulty breathing, other etiologies, such as neuromuscular disorders, inborn rapid breathing, cyanosis, wheezing, apnea, cough, rhinor- errors of metabolism, or other familial syndromes, a recent rhea, chest pain, palpitations, poor feeding, vomiting, study demonstrated that 27% of cases of DCM were diarrhea, abdominal pain, and decreased urination. Physical secondary to viral myocarditis [5]. In this study, we have examination findings collected included triage or initial vital selected cases of myocarditis and DCM that are only signs and the presence or absence of the following: presumed to be viral in etiology. We also chose to group respiratory distress, evidence of upper respiratory tract the spectrums together because ultimately the support and infection, abnormal lung examination results (wheezing, treatment are the same for both. retractions, rales, decreased air exchange), gallop, murmur, Characterizing signs and symptoms of patients with hepatomegaly, perfusion/pulses, and cyanosis. If no doc- acute myocarditis and DCM could possibly facilitate umentation existed regarding a specific sign, symptom, earlier diagnosis of the disease and help prevent medications, or other aspects of the history, it was recorded misdiagnosis. The primary objective of this study is to as “not documented.” characterize the clinical profiles of pediatric patients with Initial laboratory findings that were abstracted included acute myocarditis and DCM at the time of presentation to complete blood count, C-reactive protein (CRP), erythrocyte the hospital. A secondary objective is to review these sedimentation rate (ESR), troponin, and creatinine kinase patients' initial diagnoses early in the course of their (CK). Microbiology results were also abstracted, such as disease and to analyze cases that were initially diagnosed blood cultures, tracheal aspirate, nasal swab cultures, urine as some other condition before myocarditis or DCM cultures, endomyocardial biopsy results, and more specific was considered. viral testing. The findings of the initial chest x-ray (CXR), electrocardiogram (EKG), and echocardiogram were abstracted. The results of these tests were based on reported data in the medical record. 2. Materials and methods If patients had medical evaluations by a physician in the 14 days preceding final diagnosis of myocarditis or DCM, A retrospective cross-sectional study was conducted to the diagnoses given at these encounters were abstracted. identify patients with myocarditis and DCM who presented SPSS for Windows version 14.0 (SPSS Inc, Chicago, IL) over a 10-year span from January 1, 1994, to December 31, [6] was used for data analysis. Descriptive statistics were 2003, at 2 tertiary care pediatric centers with annual used to describe patient characteristics and frequencies of emergency department (ED) visits of 35 000 and 62 000. signs, symptoms, and diagnoses. 944 Y. Durani et al. 3. Results Table 2 Identified viral pathogens Specific viral pathogens No. of patients A total of 693 charts were reviewed at the 2 participating (n = 62) institutions. Six hundred twenty-eight patients were excluded because their heart disease was not myocarditis No pathogens identified 42 (68%) or DCM, their heart disease was secondary to another Parainfluenza 8 (13%) Coxsackie 4 (6%) primary diagnosis (eg, muscular dystrophy, metabolic Adenovirus 2 (3%) disorder), or their heart disease was caused by medications. Influenza A 2 (3%) Three
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