Philippine E-Journals

A Failing Heart (Myocarditis)

John Kenneth C. Ramos

 

Abstract:

A 9-year-old male was brought in due to sudden onset of on and off chest pain, squeezing in character, 5/10 pain scale, localized on the left anterior chest wall, non-radiating, not precipitated by pressure, deep breathing, or change in position. This was associated with 3 episodes of non-projectile vomiting and generalized body weakness. He was managed initially as shock. Patient was seen awake, coherent, and weak looking. On physical examination, he was underweight, bradycardic and hypotensive, with pale, cold clammy skin and weak pulses. Intravenous fluid resuscitation using PNSS at 20cc/kg was started. He was placed on nothing per orem, hooked to oxygen support via nasal cannula, and was started with dobutamine at 3mg/kg and penicillin G 1 million units IV every six hours. He was referred to a pediatric cardiologist. ECG revealed sinus rhythm with diffuse ischemia. Troponin T and CPK-MB were elevated. 2-dimensional echocardiography showed mitral regurgitation. For the next twenty-four hours, he had continuous chest pain and body weakness, with episodes of hypotension. Dopamine drip at 5mcg/kg/min and voluven at 230cc/hr were started. The working diagnosis this time was cardiogenic shock secondary to myocarditis. Intravenous Immunoglobulin (IVIG) was given. CRP was also elevated. Blood culture revealed growth of Klebsiella pneumonia, possible extended spectrum Beta-lactamaste (ESBL). Penicillin G was shifted to piperacillin + tazobactam and amikacin. Patient continuous improve, hence, intravenous fluid and inotropes were gradually tapered and discontinued. Upon follow up, patient had stable vital signs with no subjective complaints. Conclusion: In cases of children presenting with shock, it is of utmost importance to act fast in resuscitating the patient, to know what type of shock the patient is in, and to elicit information helpful in guiding the physician towards the most probable diagnosis. This case highlights myocarditis as one of the most important cause of cardiogenic shock. It also stresses the diagnostic dilemma physicians face in the emergency room when dealing with shock with unclear precipitating factors.