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  • Pericarditis presents with chest pain in the older child. Pleuritic or positional chest pain, fever, tachycardia, friction rub, and electrocardiographic changes may help narrow the differential.
  • Myocarditis has protean manifestations with symptom complexes that range from sudden death to signs attributable to congestive heart failure and cardiogenic shock.
  • Children with acute myocarditis should be admitted to a pediatric intensive care unit for careful monitoring and aggressive supportive management.
  • Echocardiography should be performed 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 49–1).

Table Graphic Jump Location
Table 49-1. Etiology of Pericarditis

Signs include a pericardial friction rub and tachycardia. If there is a 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


Cardiomegaly occurs on chest radiography when moderate or large pleural effusions are present (Fig. 49–1). In patients with little or no effusion, the chest radiograph is normal. The electrocardiogram may be diagnostic with diffuse ST-T wave changes. 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. It is important in guiding pericardiocentesis if drainage is necessary (Fig. 49–2).


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