Pediatric Viral Myocarditis Clinical Presentation
- Author: Edwin Rodriguez-Cruz, MD; Chief Editor: Howard S Weber, MD, FSCAI more...
Clinical presentation of viral myocarditis widely varies. In mild forms, few or no symptoms are noted. In severe cases, patients may present with acute cardiac decompensation and progress to death usually weeks after the initial viral infection and prodromal symptoms.
Heart failure is the most common presenting picture in all ages. The condition of patients who present with heart failure may rapidly deteriorate even with supportive care. Neonates and young children have higher mortality rates than older patients. Rapid supportive care with blood pressure support, afterload reduction, diuretic therapy, and control of arrhythmia may prevent early death.
Although rare in young children, chest pain may be the initial presentation for older children, adolescents, and adults. Chest pain may be due to myocardial ischemia or concurrent pericarditis.
Patients can present with any type of dysrhythmia, including atrioventricular conduction disturbances. Sinus tachycardia is typically a compensatory mechanism in patients with myocardial dysfunction, and the rate is faster than expected for the degree of fever present, which is typically low-grade. Junctional tachycardia is also seen and can be difficult to control medically.
The debate continues over whether myocarditis progresses to dilated cardiomyopathy. Many investigators believe that dilated cardiomyopathy is a direct result of a previously burned-out myocarditis episode.
Initial symptoms in infants include the following:
Periodic episodes of pallor
Failure to thrive
Older children present with similar symptoms and may experience lack of energy and general malaise. Parents of pediatric patients may refer to a recent, nonspecific, flulike illness, gastrointestinal (GI) symptoms, poor feeding, or rapid breathing.
Signs of diminished cardiac output, such as tachycardia, weak pulse, cool extremities, decreased capillary refill, and pale or mottled skin, may be present (see the Cardiac Output calculator). Heart sounds may be muffled, especially in the presence of pericarditis. An S3 may be present, and a heart murmur caused by atrioventricular valve regurgitation may be heard. Hepatomegaly may be present in younger children. Rales may be heard in older children. Jugular venous distention and edema of the lower extremities may be present in older patients.
Neonates may seem irritable, be in respiratory distress, and exhibit signs of sepsis. Somnolence, hypotonia, and seizures can be associated if the central nervous system (CNS) is involved.
Hypothermia or hyperthermia, oliguria, elevated liver enzymes, and elevated blood urea nitrogen (BUN) and creatinine levels caused by direct viral damage, low cardiac output, or both may be present.
Signs include failure to thrive, anorexia, tachypnea, tachycardia, wheezing, and diaphoresis with feeding. End-organ damage may develop because of direct viral infestation or because of low cardiac output. CNS involvement may also develop. In severe cases, low cardiac output may progress to acidosis and death.
The presentation of viral myocarditis may be similar to that in younger children but with a more prominent decrease in exercise tolerance, lack of energy, malaise, chest pain, low-grade fever, arrhythmia, and cough. End organ damage and low cardiac output may be present.
Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs. 2002. 4(3):171-81. [Medline].
[Guideline] Aretz HT. Myocarditis: the Dallas criteria. Hum Pathol. 1987 Jun. 18(6):619-24. [Medline].
Fett JD. Diagnosis of viral cardiomyopathy by analysis of peripheral blood?. Expert Opin Ther Targets. 2008 Sep. 12(9):1073-5. [Medline].
Kühl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. 2005 Sep 27. 112(13):1965-70. [Medline].
Molina KM, Garcia X, Denfield SW, Fan Y, Morrow WR, Towbin JA, et al. Parvovirus B19 myocarditis causes significant morbidity and mortality in children. Pediatr Cardiol. 2013 Feb. 34(2):390-7. [Medline].
Kawashima H, Morichi S, Okumara A, Nakagawa S, Morishima T. National survey of pandemic influenza A (H1N1) 2009-associated encephalopathy in Japanese children. J Med Virol. 2012 Aug. 84(8):1151-6. [Medline].
Lerner AM, Wilson FM. Virus myocardiopathy. Prog Med Virol. 1973. DA - 19730608:63-91. [Medline].
Kindermann I, Kindermann M, Kandolf R, Klingel K, Bültmann B, Müller T, et al. Predictors of outcome in patients with suspected myocarditis. Circulation. 2008 Aug 5. 118(6):639-48. [Medline].
Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. 2008 Sep. 29(17):2073-82. [Medline]. [Full Text].
Bowles NE, Ni J, Kearney DL, et al. Detection of viruses in myocardial tissues by polymerase chain reaction. evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol. 2003 Aug 6. 42(3):466-72. [Medline].
Renko M, Leskinen M, Kontiokari T, et al. Cardiac troponin-I as a screening tool for myocarditis in children hospitalized for viral infection. Acta Paediatr. 2009 Nov 4. [Medline].
Sun Y, Ma P, Bax JJ, et al. 99mTc-MIBI myocardial perfusion imaging in myocarditis. Nucl Med Commun. 2003 Jul. 24(7):779-83. [Medline].
Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007 Dec. 120(6):1278-85. [Medline].
Aretz HT. Diagnosis of myocarditis by endomyocardial biopsy. Med Clin North Am. 1986 Nov. 70(6):1215-26. [Medline].
Mahfoud F, Gärtner B, Kindermann M, Ukena C, Gadomski K, Klingel K, et al. Virus serology in patients with suspected myocarditis: utility or futility?. Eur Heart J. 2011 Apr. 32(7):897-903. [Medline].
Weber MA, Ashworth MT, Risdon RA, Malone M, Burch M, Sebire NJ. Clinicopathological features of paediatric deaths due to myocarditis: an autopsy series. Arch Dis Child. 2008 Jul. 93(7):594-8. [Medline].
Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995 Aug 3. 333(5):269-75. [Medline].
Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation. 1994 Jan. 89(1):252-7. [Medline].
Robinson JL, Hartling L, Crumley E, et al. A systematic review of intravenous gamma globulin for therapy of acute myocarditis. BMC Cardiovasc Disord. 2005 Jun 2. 5(1):12. [Medline].