Pericarditis presents with chest pain in the older child. Pleuritic or positional chest pain, fever, tachycardia, friction rub, and electrocardiographic changes may be noted.
Tachycardia and fatigue may be signs of myocarditis. These patients should be admitted to a pediatric intensive care unit for careful monitoring and aggressive supportive management.
Obtain echocardiography in patients with suspected myocarditis.
The at-risk patient with endocarditis presents with unexplained fever, myalgia, new murmur, and elevated acute-phase reactants.
Inflammatory diseases of the heart may affect the pericardium, myocardium, or endocardium. Pancarditis describes inflammation involving all layers of the heart. Such inflammatory cardiac disorders may be infectious, noninfectious, or rheumatologic and enter into the differential diagnosis in children presenting with complaints that range from chest pain, to acute gastrointestinal symptoms, to symptoms of cardiovascular collapse.
This chapter will discuss the presentation, diagnosis, and management of pericarditis, myocarditis, and endocarditis in children presenting to the emergency department.
Pericarditis usually follows a benign clinical course. Presenting symptoms include pleuritic or positional chest pain, fever, dyspnea, or abdominal pain. Causes overlap with those of myocarditis (Table 41-1).
Etiology of Pericarditis
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TABLE 41-1 Etiology of Pericarditis
Viral: coxsackie virus, enterovirus, adenovirus, hepatitis B virus, human immunodeficiency virus, Epstein–Barr virus, cytomegalovirus
Bacterial: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus pneumoniae, Neisseria meningitidis
Fungal: histoplasmosis, coccidioidomycosis, Candida
Other: Lyme disease, mycobacteria
Autoimmune: juvenile rheumatoid arthritis, systemic lupus erythematosus, acute rheumatic fever
Hypersensitivity to drugs
Signs include a pericardial friction rub and tachycardia. If there is a large enough pericardial effusion, one may not hear a friction rub because the visceral and parietal pleura are not apposed. As effusions increase in volume, dyspnea, or shock may develop. In the presence of pericardial tamponade, distended jugular veins and hepatomegaly may become noticeable. As cardiac output decreases because of decreased cardiac stroke volume, delayed capillary refill, decreased urine output, and hypotension develop. Pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration, may be appreciated.1
In patients with little or no effusion, the chest radiograph may be normal. Cardiomegaly is noted on chest radiography when moderate or large pleural effusions are present (Fig. 41-1). The electrocardiogram may be diagnostic with diffuse ST-T wave changes, and PR depression may occur. A decreased QRS amplitude or electrical alternans may be seen with large effusions. Echocardiography will rapidly demonstrate the presence, size, and location of a pericardial effusion and can rapidly identify cardiac tamponade using 2D and Doppler techniques.
Chest radiograph of an infant with cardiomegaly secondary to a large pericardial effusion (left). Same infant after placement of a pericardiocentesis catheter (right).
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