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8/20/2019 Myocarditis 07.15.2015
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Morning Report7/15/2015Sydney Ryan PGY3
8/20/2019 Myocarditis 07.15.2015
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+HPI
7yr old male with 23 day! o" !ore throat
#emperat$re $p to 102
%ew on!et ne&' pain
Mom endor!e! mild &onge!tion and &o$gh "or the pa!t!e(eral day! and de&rea!ed oral inta'e "or the pa!tday)
He wa! tran!"erred "rom an $rgent &are to the P*H +,"or &on&erning progre!!i(e ne&' pain)
8/20/2019 Myocarditis 07.15.2015
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+Hi!tory *ontin$ed
-irth Hi!tory. #erm male witho$t &ompli&ation!)
amily Hi!tory. Maternal hi!tory o" !tage &olon &an&erwith meta!ta!i! to li(er) %o !i&' &onta&t!) %o h/o MRSor re&$rrent !'in in"e&tion)
So&ial Hi!tory. i(e! with mom dad and one healthy!i4ling) %o &at! or dog! in the home)
8/20/2019 Myocarditis 07.15.2015
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+Hi!tory *ontin$ed
%o Ho!pitaliation!
#6 at yr old "or re&$rrent !trep in"e&tion!
PMH. %o &hroni& illne!!/$!e o" medi&ation
llergie!. %,
Medi&ation!. none reg$larly
Imm$niation!. 8p to date
R9S. :ne&' pain !ore throat "e(er de&rea!ed P9 inta'e&o$gh and &onge!tion) %egati(e "or ra!h diarrhea(omiting &hange in &on;$n&ti(a)
8/20/2019 Myocarditis 07.15.2015
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++, Ho!pital &o$r!e
dmitted to inpatient team.
,ay one. "o$nd to ha(e ne&' ma!!) *# !howedlymphadeniti! witho$t a4!&e!! "ormation) Started on
*lindamy&in and *e"tria<one) +%# wa! in(ol(ed/&on!$lted) 9(ernight. Re!ident &alled to 4ed!ide "or low $rine o$tp$t
ta&hy&ardia and "e(er) l!o noted to 4e (omiting witha4dominal pain)
8/20/2019 Myocarditis 07.15.2015
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+Phy!i&al +<am
#emp. 3=)0 RR.52 HR. 152 -P. =>/0 9<ygen. =5?2@ on room air
General. in moderate di!tre!!
H++%#. normal !&lera no na!al drainage le"t !ided !$4mandi4$larma!! that wa! tender to palpation) Pain with ne&' mo(ement)
*A. ta&hy&ardi& heart !o$nd! were diB&$lt to a!!e!! &apillaryreCll 3!e&ond! !trong p$l!e! peripherally
R+SP. #a&hypni& !$4&o!tal retra&tion! no wheee!
4d. !o"t nontender nondi!tended) -S pre!ent
S'in. 4lan&hing ma&$lar ra!h on palm! and !ole!
%e$ro. *% IIDII inta&t +9MI p$pil! eE$al and re!pon!i(e to light)%o "o&al deC&it!)
8/20/2019 Myocarditis 07.15.2015
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+*a!e
#hi! i! a 7year old male with 3day! o" ne&' pain "e(er and (iral
!ymptom! in the !etting o"lymphadeniti! who a&$tely
de(eloped ta&hy&ardia re!piratory
di!tre!! (omiting and a4dominalpain)
8/20/2019 Myocarditis 07.15.2015
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+,iFerential ,iagno!i!
GI Ga!triti!
,ehydration
94!tr$&tion
Int$!!$!&eption
Infectious
Progre!!ion o" (iral illne!! Septi& !ho&'
Pne$monia
4!&e!! "ormation
-ron&hioliti!
e(er
emierre! !yndrome ;$g$lar (eno$!throm4ophle4iti!
+-A
awa!a'i ,i!ea!e
Pulm/airway Inter!titial C4ro!i!
irway o4!tr$&tion "rom ma!! P$lmonary edema
Neuro Meningiti!
+n&ephalopathy
Cardiac rrhythmia
*ardia& #ampanode
+ndo&arditi!
Peri&arditi!
Myo&arditi!
Other *hemi&al e<po!$re
Ste(enJohn!on! !yndrome/dr$gerr$ption
Sar&oido!i!
$p$!
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+a4oratory Re!$lt!
#roponin. 3)2
*M- 15
-%P 100
*-*. 12)2 K-* 13)? hg4 2?0 plt! 23@4and!5=@ne$trophil 13@lympho&yte!
*MP. normal
ARP. Rhino :
8/20/2019 Myocarditis 07.15.2015
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+9ther ,ata
8/20/2019 Myocarditis 07.15.2015
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+9ther ,ata
+*H9 re!$lt!.
Mildly de&rea!e A "$n&tion normal !ie
Mild #ri&$!pid reg$rgitation and mitral (al(e reg$rgitation
Mildly de&rea!e PA "$n&tion normal !ie Small peri&ardial eF$!ion
8/20/2019 Myocarditis 07.15.2015
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+9ther ,ata
Sin$! ta&hy&ardia diF$!e S# a4normality and prolonged L#&
8/20/2019 Myocarditis 07.15.2015
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,iagno!i!. i'ely AiralMyo&arditi!
8/20/2019 Myocarditis 07.15.2015
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+Myo&arditi!
Pathophy!iology. &ell$lar damagemyo&ardialdy!"$n&tionheart "ail$re
8/20/2019 Myocarditis 07.15.2015
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+Myo&arditi! +tiology
Airal. *o<!a&'ie(ir$! type! and - deno(ir$! type 2and 5 Hepatiti! * Par(o(ir$! -1? +-A and *MAHerpe! (ir$! +&ho(ir$! HIA In$ena parain$enamea!ele! r$4ella
-a&terial. Staph Strep #$l$remia -r$&ella Heamophil$!
meningo&o&&al #- legionella and other!
In"e&tio$!. Ri&'ett!ial Protooal Helminthi& et&
*ardioto<in!. al&ohol &o&aine ar!eni& &ar4on mono<ide
and hea(y metal!
Sy!temi& di!ea!e. !ar&oido!i! I-, *elia& di!ea!eawa!a'i di!ea!e $p$!
Hyper!en!iti(ity rea&tion!. in!e&t 4ite! !na'e 4ite!
di$reti&! anti4ioti&!
8/20/2019 Myocarditis 07.15.2015
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+Myo&arditi!Pre!entation
Prodrome !e(eral day! prior. "e(er malai!e myalgia!
&$te pre!entation heart "ail$re. re!t e<er&i!e intoleran&e
!yn&ope ta&hypnea ta&hy&ardia and hepatomegaly
9ther!. re!piratory di!tre!! or ga!trointe!tinal !ymptom!anore<ia a4dominal pain and (omiting arrhythmia! andheart 4lo&'
$lminant myo&arditi! poor o$tp$t. hypoten!ion poor
p$l!e! and de&rea!ed per"$!ion a&ido!i! andhepatomegaly whi&h may progre!! to &ardio(a!&$lar&ollap!e
9% +DM. S gall$p m$rm$r!
8/20/2019 Myocarditis 07.15.2015
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+Myo&arditi!
Initial #e!ting.
+*G. a4normal altho$gh &hange! are neither !pe&iC& nor!en!iti(e) *hange! in&l$de S# !egment and in(erted #wa&e! a4normal a<i! (entri&$lar/atrial enlargement andde&rea!ed (oltage
-%P. %on!pe&iC&
#roponin and *M- "or a more a&$te pre!entation (!dilated &ardiomyaopathy
*he!t <ray. 4normal in a4o$t hal" that patient! with&ardiomegaly and p$lmonary &onge!tion
-lood ga! may ree&t poor per"$!ion with meta4oli&a&ido!i!
9ther. MRI with &ontra!t inammation -iop!y
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+Myo&arditi!
#hree Pha!e!.
Airal In"e&tion pha!e. Prodome o" !e(eral day!. "e(ermalai!e mylagia! GI !ymptom!
$toimm$ne/Inammatory pha!e. # &ell and &yto'inea&ti(ationheart "ail$re
,ilated *ardiomyopathy pha!e. !mall !$4!et
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+Myo&arditi!
#reatment.
,$e to the high ri!' o" arrythmia! they !ho$ld 4e inthe PI*8
Initial !$pporti(e treatment &on!i!t! o" e<ogeno$!o<ygen deli(ery &are"$l $id re!$!&itation n$tritional!$pport and po!!i4le 4lood tran!"$!ion to in&rea!eo<ygen &arrying &apa&ity) In !ome &a!e! more
!igniC&ant !$pporti(e &are eg intra(eno$! inotropi&!$pport me&hani&al (entilation and me&hani&al&ir&$latory !$pport may 4e needed d$ring the a&$teillne!! prior to myo&ardial re&o(ery and in other &a!e!patient! will progre!! to end!tage dilated
&ardiomyopathy and reE$ire &ardia& tran!plantation "orlongterm !$r(i(al)
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+Myo&arditi!
#reatment &ont
,i$reti&!
Pre(ention o" &ir&$latory &ollap!e. Milronone ,opamine
do4$tamine 9ther &on!ideration! no o4(io$! 4eneCt in !t$die!. anti
arrythmi&! IAIG anti(iral! &orti&o!teroid!
8/20/2019 Myocarditis 07.15.2015
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+Myo&arditi!
Progno!i!.
#he ma;ority o" patient! e(ent$ally re&o(er &ompletely
Some reE$ire heart tran!plant dilated &ardiomyopathy
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+Re"eren&e!
*atherine llan M, et al) 8p#o,ate. *lini&almani"e!tation! and diagno!i! o" myo&arditi! in &hildren)Mar 13 201)
*atherine llan M, et al) 8p#o,ate. #reatment andprogno!i! o" myo&arditi! in &hildren) Mar&h 13 201)
+dwin Rodrig$e*r$ M,) +medi&ine. Pediatri& AiralMyo&arditi!) $g 2? 2013
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