Early recognition may help save a life.
Takeaways:
- Nurses should have a high suspicion for serious illness such as myocarditis in pediatric patients who present with respiratory distress that fails to respond to standard treatment.
- Myocarditis has high rates of morbidity and mortality in children, so nurses should be aware of its causes and symptoms.
Samantha Thomas*, 19 months old, presents to the emergency department (ED) with a 2-day history of fever, cough, and wheezing. Her parents say that she’s been more tired than usual and has a decreased appetite, but she’s drinking milk and has had five wet diapers in the past 24 hours. Samantha has a history of reactive airway disease (wheezing with upper respiratory infections) but is otherwise healthy. Her parents have been giving her 2.5 mg of albuterol via nebulizer every 4 hours, as prescribed. Her last nebulizer treatment was an hour before arriving at the ED.
Samantha is lethargic, has intercostal and suprasternal retractions, and is audibly wheezing. Her vital signs are temperature 101.6° F (38.7° C), HR 144 bpm, RR 48 breaths per minute, and Sao2 95% on room air. You give her acetaminophen 15 mg/kg, as prescribed.
History and assessment hints
Samantha has clear nasal discharge, diffuse wheezing, increased work of breathing, and erythematous cheeks. Her parents state that Samantha seems much sicker than she typically gets with a respiratory infection. She’s given a 2 mg/kg loading dose of prednisolone and nebulized albuterol and ipratropium bromide via facemask, as ordered by the provider. When you reassess Samantha 20 minutes after the nebulizer treatment, you observe nasal flaring, worsening retractions, belly breathing, and diffuse wheezing. Her vital signs are temperature 100.5° F (38° C), HR 216 bpm, RR 62 breaths per minute, and Sao2 92% on room air.
On the scene
Noting Samantha’s rapidly worsening condition, you notify the provider, who orders a chest X-ray, an ECG, and a second albuterol and ipratropium bromide nebulizer treatment with 2 L of oxygen. The X-ray shows an enlarged cardiac silhouette, and the ECG shows non-specific T-wave abnormalities and sinus tachycardia. The provider consults a cardiologist, who, based on Samantha’s history, physical, ECG, and results of a bedside echocardiogram diagnoses her with myocarditis and admits her to the cardiac intensive care unit (CICU). A myocardial biopsy is positive for Parvovirus B19.
Outcome
In the CICU, Samantha is intubated, placed on a ventilator, and given nutrition via a nasogastric tube. The cardiologist orders I.V. immune globulin and hemodynamic support with lisinopril and furosemide. After 2 days, Samantha is extubated. Over the next 2 weeks, her condition continues to improve, and she’s discharged home on lisinopril. At the 6-month follow-up, Samantha is an active toddler who doesn’t need cardiac medications.
Education and follow-up
Parvovirus B19 causes Fifth disease, a common childhood illness characterized by fever, upper respiratory symptoms, lacy pink rash, and a “slapped cheek” appearance. It’s usually mild and self-limiting. In rare cases such as Samantha’s, it can cause myocarditis, an inflammation of the heart muscle. In children, the most common causes are viruses such as Parvovirus B19, Coxsackie virus, and influenza. Symptoms of myocarditis vary but may include chest pain, respiratory and GI distress, and lethargy. The increase in Samantha’s heart rate despite her fever decreasing was a key finding.
Although rare, myocarditis can lead to heart failure and death if it’s not rapidly diagnosed and treated. In milder cases such as Samantha’s, care is supportive and consists of antiarrhythmics, diuretics, and supplemental oxygen to treat symptoms of acute heart failure. Severe cases may result in dilated cardiomyopathy, heart transplant, and death.
Rapid recognition of a patient’s failure to respond to standard treatment is important to providing the best possible outcome. In Samantha’s case, it may have saved her life.
Olivia Sasher is a presurgical pediatric nurse practitioner at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.
References
Butts RJ, Boyle GJ, Deshpande SR, et al. Characteristics of clinically diagnosed pediatric myocarditis in a contemporary multi-center cohort. Pediatr Cardiol. 2017;38(6):1175-82.
Vigneswaran TV, Brown JR, Breuer J, Burch M. Parvovirus B19 myocarditis in children: An observational study. Arch Dis Child. 2016;101(2):177-80.
