Pediatrics Case Conference Date 0227 2008 Presented by

Pediatrics Case Conference Date: 02/27, 2008 Presented by R 3 許太乙 Instructor: 吳孟書醫師

Patient’s General Profile n n 陳XX, 10 y/o boy Chart No. 3458854 Arrival time: 20: 06, 02/09, 2008 檢傷主訴: 胸痛 Vital signs: T/P/R: 37. 0/126/20 n BP: __/__ , E 4 V 5 M 6, Sa. O 2: 98%, BW: 47 Kg n n 檢傷分類: 3級

Chief Complaint n Chest tightness noted tonight and yesterday

How to Approach a child with chest pain ? What else should be added?

History Taking of Chest pain: PQRST n Provocation: n n Palliation: n n Squeezing, pressure, tightness vs. stabbing, sharp Region/Location: Radiation: n n Antacid, NTG, rest, position Quality of pain: n n Exertion, diet, deep breath, motion or position Neck, lower jaw, shoulder, arms, back Severity: Time: n n Abrupt, gradual, vs. Vague onset Duration

History Taking ~ Associated Symptoms n n n n Nausea, vomiting Belching, painful swallowing Diaphoresis Dyspnea Cough Syncope Palpitation Fever

Personal & Family History for Chest Pain in Children n Underlying disease: n n Family History: n n Asthma, Cardiac disease, Kawasaki disease, sickle cell disease Marfan syndrome, Turner syndrome, Type IV Ehlers-Danlos syndrome ( Risk of Aortic dissection); Hypertrophic cardiomyopathy Others: Substance use in adolescence ( Cocaine, tobacco )

PE for Chest Pain n n n General appearance Vital signs/ Bilateral arms BP Chest wall palpitation, Skin lesion Breath sounds Heart sounds Abdomen PE

History may be added n n n The onset, duration, quality of the pain Radiation, aggravated or relief factors Associated symptoms

What is your impression of his chest pain ?

Relative Frequency of Causes of Chest Pain in Children n n n Idiopathic: 12%~85% Musculoskeletal: 15%~43% Respiratory: 12%~21% Psychogenic: 5%~17% Gastrointestinal: 4%~7% Others: 4%~21% Cardiac: 0%~4% ~ Park: Pediatric Cardiology for Practitioners, 5 th ed. 2008

Differential Diagnosis of Chest Pain in Children n Musculoskeletal n n n n Costochondritis ( Most left 4 th) Slipping rib syndrome (8, 9, 10 th ribs) Precordial catch( Texidor’s twinge) Cardiovascular ( Rare in children) n n Myocarditis* Pericarditis Acute coronary syndrome* n Aortic dissection* Breast: n n FCD, Thelarche Pulmonary n Pleuritis n Pneumonia n n n Pulmonary embolus* (rare ) Pneumothorax* Acute chest syndrome ( sickle cell disease) Psychiatric n n Anxiety disorders Hyperventilation Toxic Exposure n Coccaine, Marijuana n Gastrointestinal n Esophageal n n n Peptic ulcer disease n n n Esophagitis Spasm Reflux Rupture* PPU* Pancreatitis( rare) Biliary ( rare) n n n Cholangitis Cholecystitis Colic ~ Up. To. Date, 2008

Differential Diagnosis of Chest Pain in Children n n Musculoskeletal Pulmonary n Pleuritis n Pneumonia n Pneumothorax Gastrointestinal n Esophagitis n PPU, Pancreatitis, biliary colic, Cardiovascular n Myocarditis n Acute coronary syndrome n Aortic dissection Psychiatric

ER Order at 21: 23(01: 17) n n n Acetaminophen 500 mg 1# qid po Dioctahedral smectite powder 1 pk bid po Lactobacillus casei 250 mg 1# bid po CXR On Saline lock CBC/DC, AST, CK-MB, Tn-I

CXR

CBC/DC at 21: 29( 01: 20) n n n n RBC: 4. 50 m/u. L L n Hemoglobin: 12. 4 g/d. L n Hematocrit: 36. 6 % n MCV: 81. 3 f. L n MCH: 27. 6 pg/Cell n MCHC: 33. 9 g/d. L RDW: 13. 2 % Platelets: 273 K/u. L WBC: 10. 2 K/u. L Segment: 67. 0 % Lymphocyte: 26. 0% Monocyte: 5. 0 % Eosinophil: 2. 0 %

Biochemistry at 21: 45(01: 39) n n n AST (GOT): 24 U/L CK-MB: 7. 8 ng/m. L Troponin-I: 1. 928 ng/m. L !!!

ER order added at 22: 32(02: 23) n n n ALT, Cr, BUN, Sugar, Complete EKG Admitted to 兒童心臟科 PICU On EKG, BP monitor, and pulse oximeter On critical: 心肌炎 (家屬拒簽) IVF change to N/S keep open O 2 nasal 5 L/min

Biochemistry added n n ALT(GPT): 17 U/L BUN: 9 mg/d. L Cr: 0. 5 mg/d. L Sugar: 127 mg/d. L

EKG: Sinus Tachycardia, Non-specific ST-T change

Hospital Course n 02/09 n n 02/10: n n Admission to PICU; f/u Tn-I q 12 h, check viral titer 2 -D echo: good LV performance without pericardial effusion 02/11: Transfer to ward 02/12: No chest pan, still diarrhea 02/14: No diarrhea, MBD

Troponin-I Levels

Virus Study n n n n n EB-VCAG EB-VCAM COX-B 1 COX-B 2 COX-B 3 COX-B 4 COX-B 5 COX-B 6 EBEA-Ab EBNA-Ab Negative 1: 2 (+) 1: 4 (+) 1: 2 (-) 1: 8 (+) Negative

Final Diagnosis n n Acute myocarditis Acute enteritis

Myocarditis in Children n Cause: Infections, toxic, autoimmune n n Most~ Virus: Coxsackie group B, Adenovirus Incidence: unknown ( may asymptomatic) Autopsy in sudden death: 3~ 40% n Autopsy in SIDS: 17% n ~ Up. To. Date 2008

Myocarditis in Children Clinical Manifestations n Prodrome symptoms: n n Dyspnea at rest, exercise intolerance, syncope, tachycardia, hepatomegaly Respiratory distress: most prominent sign n n Viral: Prodrome of fever, myalgia, malaise Autoimmune: Systemic symptoms ~ incorrect initial diagnosis of lower respiratory infection Some cases: asymptomatic Fulminant myocarditis: hemodynamic compromise Unexpected death: Ventricular arrhythmia ~ Up. To. Date 2008

PE in Myocarditis n n n Signs of respiratory distress S 3 and occasionally S 4 gallops Murmrus: RV or LV dilation MR, TR Fulminant myocarditis: signs of shock Some may have pericardial friction rub ~ Up. To. Date 2008

Diagnostic Study in Myocarditis n n CXR: cardiomegaly, pulmonary congestion EKG: nonspecific, most sinus tachycardia; n n Cardiac Enzyme: Tn-I/T more sensitive than CK-MB n n n Some ~ VPC, APC, SVT, AV block 2 Biopsy proven studies: 34%: 6% & 53%: 2% 2 -D: LV dysfunction MRI: document the location & extent ESR, CBC/DC ( nonspecific), ABG Virus culture( Rectal & nasal swab), PCR Autoimmune study ~ Up. To. Date 2008

Cardiac Catheterization n Reveals cardiac index, LVEDP, MAP, etc Endomyocardial biopsy: gold standard Dallas criteria: low sensitivity; 20~ 50% Sampling error increase biopsy number n Immunocytochemistry improve sensitivity n n Complication: ~1% n Perforation of RV, arrythmia, pneumothorax, flailed tricuspid leaflet ~ Up. To. Date 2008

Treatment n n n Monitor, supportive care, Heart failure: diuretics, afterload reducing, inotropics Arrhythmia: Lidocaine 1 st line n n n Amiodarone ~ proarrhythmic, hypotension; Consult CV Complete heart block: transvenous pacing ECMO, VAD Immunosuppressive & Corticosteroids: controversial IVIG: 2 g/kg over 24 hours n No randomized study, a trend toward improving survival in 1 year ~ Up. To. Date 2008

Prognosis of Myocarditis in Children n A retrospective study: 41 pt follow 5 years n n 66% complete recover, 10% partial, 24% died or require transplantation 21 children with IVIG vs other 25 children n Survival in 1 year: 84% vs 69% ~ Up. To. Date 2008

Thanks for your attention!

會後討論~2 n n n 一旦用到Dopamine、Dobutamine。就要想 到使用ECMO。 雖然Up. To. Date上面推薦Lidocaine。但對於 這種arrhythmia我們多使用Amiodarone； Lidocaine效果不佳。 兒科有兩種cases容易有糾紛。一個是 Myocarditis, 一個是Intussusception。因此 要特別注意。