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HIGH-YIELD FACTS

  • Older children with pericarditis most often present with chest pain in combination with other symptoms. Fever, tachycardia, friction rub, and electrocardiographic changes may be noted.

  • Tachycardia and fatigue may be signs of myocarditis. Acutely ill 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 categorized anatomically. The pericardium, myocardium, or endocardium may be involved. Pancarditis describes inflammation involving all layers of the heart. Inflammatory cardiac disorders are caused by a number of etiologies and are a consideration in children presenting with symptoms ranging from nonspecific to cardiovascular collapse.

This chapter discusses the presentation, diagnosis, and management of children presenting to the emergency department with inflammatory or infectious disease of the heart.

PERICARDITIS

Pericarditis may be categorized as infectious, noninfectious, or idiopathic. The underlying etiologies overlap with those of myocarditis. Recurrent cases of pericarditis are usually idiopathic or viral.1 Causes overlap with those of myocarditis (Table 42-1).

The diagnosis of pericarditis in a pediatric patient is a clinical challenge. In patients without a history of cardiac surgery or a condition that would predispose them to pericarditis, chest pain is the most common presenting symptom. Chest pain is often worsened with deep inspiration, and alleviated by leaning forward. Younger children may not be able to describe chest pain. While chest pain is present in more than 90% of patients, it is rarely the sole presenting symptom.2 Fever, vomiting, cough, shortness of breath, and fatigue are the most common other symptoms and are most often accompanied by chest pain.2

TABLE 42-1Etiology of Pericarditis

Physical examination findings include tachycardia and a pericardial friction rub, although the identification of a rub may be uncommon.2 With a large enough pericardial effusion, one may not hear a friction rub because the visceral and parietal pleura are not opposed. As effusions increase in volume, dyspnea or shock may develop. In the presence of pericardial tamponade, jugular venous distention and hepatomegaly may be noted on physical examination. Cardiac output decreases secondary to decreased cardiac stroke volume. Delayed capillary refill, decreased urine output, hypotension, and pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration may develop.3

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