1. PED CHEST PAIN AND MYOCARDITIS Reporter : Dr. Meng-Shu Wu Lin Kao CGMH ED

2. Introduction  A common symptom in children and adolescents.  No gender predilection.  Having important functional consequences.  Benign in most cases.  Because of its association with fatal heart disease in adults, this symptom often is viewed as a harbinger of serious cardiac disease.

3. What are the patients and their parents understood and concerned? CausePrevalence, percent Cardiac52 to 56 Muscoskeletal13 Respiratory tract10 Skin infection3 Breast3 Cancer0 to 12 Unsure10 to 19

4. Causes of pediatric chest pain CausePrevalence, percent Idiopathic21 to 45 Muscoskeletal15 to 31 Hyperventilation/psychiatric0 to 30 Breast related1 to 5 Respiratory2 to 11 Gastrointestinal2 to 8 Cardiac1 to 6 Miscellaneous9

5. Musculoskeletal conditions  Traumatic: a. Rib fracture b. Hemopneumothorax c. Bruise  Non-traumatic: a. Costochondritis - left 4th b. Slipping rib syndrome - 8th, 9th, and 10th c. Precordial catch - Texidor's twinge

6. Psychogenic causes  More common in children ≧ 12 y/o  Anxiety or a conversion disorder triggered by stressful events.  Other recurrent somatic complaints.  Hyperventilation

7. Breast causes  Males with gynecomastia.  Mastitis  Fibrocystic disease  Thelarche  Tenderness associated with pregnancy.  Worries about cancer are often present in these patients.

8. Toxic exposure  Cocaine  Marijuana  Methamphetamines  Sympathomimetic decongestants  Cigarette smoking

9. Respiratory disorders  Pneumonia  Bronchitis  Reactive airway disease  Pleuritis  Pleural effusion  Pneumothorax  Pneumomediastinum

10. Gastrointestinal disorders  Gastroesophageal reflux  Gastritis  Diffuse esophageal spasm and achalasia  Esophageal strictures, foreign body, and caustic ingestions

11. Pulmonary vascular disease  Pulmonary embolism - major risk factors were oral contraceptive use and pregnancy termination and trauma.  Pulmonary hypertension - fatigue, lethargy, and dyspnea or syncope with exertion.  Acute chest syndrome - a serious and potentially fatal cause of chest pain in patients with sickle cell disease.

12. Cardiac conditions  Cardiac disease is more likely if chest pain occurs during exertion and is recurrent.  Most conditions will be associated with an abnormal cardiac examination or coexisting symptoms.  In patients with known heart disease, chest pain may indicate progression of the underlying condition.

13. Cardiac conditions  Severe left ventricular outflow tract obstruction caused by aortic stenosis (subvalvar, valvar, or supravalvar), obstructive cardiomyopathy, or coarctation of the aorta.  Aortic root dissection associated with Marfan syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome…..  Pericarditis  Myocarditis  Coronary artery abnormalities, including congenital disorders or acquired conditions (eg, coronary artery aneurysm or stenosis caused by Kawasaki disease).  Ruptured sinus of Valsalva aneurysm  Tachyarrhythmias or palpitations.  Coronary vasospasm (variant angina) and myocardial infarction  Mitral valve prolapse

14. Neurologic disorders  Herpetic neuralgia  Spinal cord compression

15. History  Description of chest pain 1) Time course 2) Duration 3) Quality 4) Location 5) Radiation 6) Severity 7) Precipitating factors 8) Associated symptoms  Underlying medical conditions  Family history  Drug and medication history

16. Physical Examination 1. Chest wall - palpation, "hooking" maneuver…. 2. Respiratory signs 3. Cardiac signs - auscultation of abnormal heart sounds or a cardiac murmur or abnormal pulse or blood pressure.

17. Diagnostic Studies  12-lead resting EKG  CxR  Echocardiogram  Gastrointestinal evaluation  Other tests Laboratory testing is necessary only in a small number of patients.

18. Normal physical examination

19. Evaluation of pediatric chest pain - abnormal physical examination

20. Myocarditis  Myocarditis is a condition resulting from inflammation of the heart muscle.

21. Major Causes of Myocarditis  Infectious – particularly virus  Toxin  Autoimmune etiologies

22. Clinical Menifestations  Variable  Viral prodrome of fever, myalgia, and malaise several days prior to the onset of heart failure.  Symptoms of systemic autoimmune disease.  Signs and symptoms of heart failure.  Tachycardia and metabolic acidosis may be important indicators of the extent of myocardial involvement.  Arrhythmias

23. Physical Examination  Signs of respiratory distress  S3 and occasionally S4 gallops  Heart murmurs  Signs of low cardiac output  A pericardial friction rub

24. Diagnostic Studies  CxR  12-leads resting EKG  Echocardiogram  Cardiac ezymes - They are seen in some, but not all, patients with myocarditis.  MRI  Cardiac catheterization  Cardiac catheterization  Endomyocardial biopsy — the gold standard for the diagnosis of myocarditis.

25. Treatment  Heart failure - diuretics, afterload reducing agents, and inotropic drugs, ET+MV, and ECMO if necessary.  Antiarrhythmic drugs  Immunosuppressive therapy  Corticosteroids  IVIG Recommendation — We use high dose IVIG (2 g/kg over 24 hours) for children with acute myocarditis demonstrated by endomyocardial biopsy. We reserve the use of corticosteroids or other immunosuppressive agents for myocarditis associated with systemic autoimmune diseases.