Pediatric Viral Myocarditis Clinical Presentation
- Author: Edwin Rodriguez-Cruz, MD; Chief Editor: Stuart Berger, MD more...
History
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.
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, 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 typical, 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:
- Irritability
- Lethargy
- Periodic episodes of pallor
- Fever
- Hypothermia
- Tachypnea
- Anorexia
- 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.
Physical Examination
Signs of diminished cardiac output, such as tachycardia, weak pulse, cool extremities, decreased capillary refill, and pale or mottled skin, may be present. 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.
Neonates
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.
Infants
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.
Adolescents
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. Jun 1987;18(6):619-24. [Medline].
Fett JD. Diagnosis of viral cardiomyopathy by analysis of peripheral blood?. Expert Opin Ther Targets. Sep 2008;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. Sep 27 2005;112(13):1965-70. [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. Aug 5 2008;118(6):639-48. [Medline].
Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. Sep 2008;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. Aug 6 2003;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. Nov 4 2009;[Medline].
Sun Y, Ma P, Bax JJ, et al. 99mTc-MIBI myocardial perfusion imaging in myocarditis. Nucl Med Commun. Jul 2003;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. Dec 2007;120(6):1278-85. [Medline].
Aretz HT. Diagnosis of myocarditis by endomyocardial biopsy. Med Clin North Am. Nov 1986;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. Apr 2011;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. Jul 2008;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. Aug 3 1995;333(5):269-75. [Medline].
Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation. Jan 1994;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. Jun 2 2005;5(1):12. [Medline].
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