Case history
Case history #1
A 43-year-old man with no significant medical history presents with 3 days of progressive fatigue, dyspnea on exertion and while lying in the supine position, and lower extremity swelling. He reports having a flu-like illness consisting of fevers, myalgias, fatigue, and respiratory symptoms 2 weeks prior that resolved spontaneously. On examination the patient has an elevated jugular venous pressure, bilateral pulmonary rales, and a heart rate of 104 bpm with an audible left ventricular S3 gallop. He is mildly dyspneic at rest but becomes markedly dyspneic with minimal exertion.
Case history #2
A 4-year-old child with a 4-day history of abdominal pain, vomiting, and low-grade fever presents to the emergency room with lethargy. His parents report that prior to this illness, he was a completely healthy child with an excellent energy level. On exam, the patient has resting tachycardia of 130 bpm, has labored breathing, poor tone, poor capillary refill, and is very lethargic. He has S3 gallop and an early systolic murmur. Mild crackles throughout the lung fields are noted.
Other presentations
The clinical manifestation of myocarditis is highly variable and ranges from asymptomatic ECG abnormalities to cardiogenic shock.[5][15] When cardiac involvement manifests clinically, it typically occurs 7-10 days after a systemic illness. Chest pain occurs in 35% of patients and may be typical, atypical, or positional in nature.[4][16] Occasionally, patients present with ischemic-sounding chest pain and ST-segment elevations on ECG that mimic acute coronary syndrome. Left ventricular dysfunction tends to be global instead of regional, and coronary angiography is normal.[17] Patients with myocarditis may present with sudden cardiac death, usually due to ventricular arrhythmias; myocarditis has been identified in up to 6% of young athletes with sudden cardiac death in the US.[18]
It is important to remember that in children, myocarditis will often mimic common childhood illnesses with symptoms such as abdominal pain, vomiting, fever, cough, and poor appetite. Respiratory symptoms are often late in their presentation. Children may also present with decreased activity level as the only persistent finding after a bout of viral prodrome. Thus, having a high index of suspicion is key in pediatric myocarditis.
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