more than man-flu (part2)…

Here is the follow-up to the story of our 19 year old febrile patient…..

The case continues…

His CXR demonstrates the following ….

• Clear lung fields
  • No pneumonia
  • No CCF
• is that a ‘globular heart’  ??

This is his ECG…

Sinus tachycardia. Non-specific T-wave changes, but no ST-segment changes.

My thoughts at this stage were;

• 19 year olds should be able to stand on their own
• Constitutional symptoms… ?viral illness
• I cannot exclude concomitant sepsis –> so treated with empiric ABx / fluids
• Globular heart silhouette

 ** Is this myocarditis ?? **

Troponin elevated to 25 (Normal <5).

I took the USS to his bedside for a peek at his heart (biggest regret in this case is not recording his images, sorry)….

• Pericardial fluid ~ 0.5-1cm circumferentially.
  • RA/RV not obviously collapsing
• Large LV which did not appear to contract appropriately
  • I would have expected a febrile, tachycardic young person to have hyperdynamic function/contractility.

The biggest challenge of this case was convincing the cardiology service that this was ‘more than man-flu’ and this young fella needed admission and further investigations…

In short, he went to a monitored bed & stayed in hospital for 4 days;

• ECHO on Day 1 = Moderate dilated cardiomyopathy with LVEF ~35% & small pericardial fluid.
• Commenced on ACE-inhibitor….
• Viral serologies negative.
• Discharge Dx = dilated cardiomyopathy secondary to presumed viral myocarditis.

The discussion:

MYOCARDITIS.

Myocarditis is inflammation of the heart muscle & frequently accompanies pericarditis. Because many episodes are mild, they do not always come to medical attention.

The mortality from myocarditis remains high (20% @ 1 year, 50% @ 5years).

Clinical Features:

Flu-like symptoms (fever, fatigue, myalgias & vomiting +/- diarrhoea) are usually the first symptoms & signs. These can be associated w/ altered vital signs, particularly fever, tachycardia & tachypnoea.

Cardiac examination is often unremarkable. However, chest pain &/or CHF at initial presentation carries a worse prognosis.

In children, respiratory distress (retractions & grunting) is common.

Helpful Investigations:

ECG:

• Sinus tachycardia & low electrical activity.
• Evidence of long-QT, AV block or AMI pattern abnormalities.

Bloods:

• Troponin often elevated.
• WCC / ESR = nonspecific.
• Viral serology / titers (unhelpful in the ED).

CXR:

• Nonspecific or normal. Cardiomegaly or ‘globular heart’.
• Pulmonary venous congestion / APO in severe disease.

ECHO:

• Reduced LVEF, global hypokinesis & regional wall motion abnormalities.

Management & Disposition.

The type of supportive care required is determined by the clinical presentation and the stage/severity of disease.

A spectrum exists including; activity limitation, treatment of heart failure, ECMO, LVADs & transplantation. (Immunosuppressive medication yet to be proven effective).

All patients should be monitored. Those with abnormal vital signs require ICU.

Complications include; ventricular dysrhythmias, LV aneurysm formation & cardiac failure.

The summary:

• Young people can have significant pathology
• Trust your gestalt if something doesn’t feel quite right.
• Don’t let people argue against your better judgement over the phone, you have the benefit of seeing the patient first hand…
• You don’t have to have evidence of cardiac failure with myocarditis, especially if it presents early (remember, these are the potentially the patients we can do the most for).

Hope you found this helpful,

Chris.