Case of the Month – April 2017

Keeping with the pediatrics theme, here is the freshest installment of Case of the Month.

A 15 year-old boy with no significant past medical history presents to the Janus ED with chest pain and decreased oral intake over a two day period. He complains of nausea with two episodes of non-bloody, non-bilious emesis.  He feels tired with minimal physical activity. His mom notes a cough that is worse at night. The patient denies any abdominal pain but does not feel hungry. There are no sick contacts at home, there is no rash, and his immunizations are all up to date. Of note, he was seen in his primary care doctor’s office a couple of weeks ago for an upper respiratory infection, when he presented with cough, fever, myalgias, and generalized malaise. Those symptoms have since resolved.

NKDA

No OTC meds

SH: Denies toxic habits; good student in school per mom

 

Physical exam:

VS: HR 105 RR 30 BP 100/55 SaO2 98% (RA) T 101.3 degrees F (temporal)

General: Young boy lying in stretcher in moderate respiratory distress

HEENT: No scleral icterus or conjunctival pallor; no oropharyngeal erythema or exudates, uvula midline, moist mucous membranes; bilateral clear TMs; nasal turbinates clear and not boggy

CV: Tachycardia, normal S1S2, S3 noted, 2/6 systolic murmur in the apex, no rubs or gallops

Pulm: Tachypnea, nasal flaring, suprasternal retractions, bibasilar crackles

Abd: Soft, non-distended, non-tender, dull to percussion, +normoactive BS; liver palpable 2 cm below costal margin, no splenomegaly

Ext: no C/C/E

Derm: No skin changes noted on trunk, abdomen, oral mucosa, palms, or soles

 

ECG:

Chest X-ray:

Labs:

14.5>14|42<475

CMP: within normal limits

So…

  • What is your differential diagnosis? Which diagnosis is most likely, and which is less likely?
  • What further tests would you do?
  • What is your therapeutic plan?
  • What is the ultimate disposition for this patient?
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rithvikb

Resident Physician, EM/IM  

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2 comments for “Case of the Month – April 2017

  1. eschnitz
    April 13, 2017 at 4:07 pm

    differential diagnosis includes myocarditis, endocarditis, pneumonia, rheumatic heart disease. myocarditis most likely vs endocarditis. Would get blood cultures, troponin, bnp, echo.
    admit to PICU depending on official US. antibiotics for vegetions if present. PICU if effusion on US

    -schnitz

  2. Raul Hernandez
    April 21, 2017 at 10:41 pm

    I agree with Schnitzer that myocarditis is the most likely diagnosis. Would also add to the differential for likely culprits pneumonia (for a nasty, purulent pericardial effusion… It’s like vanilla frosting for your heart! Yum!) lupus (eat your heart out, Dr. House!), tuberculosis, and HIV. It may even be malignancy. Given the history of the URI symptoms prior to the current presentation I might also add to the work up anti-streptolysin O, HIV (depending on the history the kid gives you when get mom out of the room), and the blood cultures should also include fungal cultures. It might be worth sending those acronym heavy rheumatologic studies for the sake of expediting the inpatient work up since this kid is going straight to an upstairs bed preceded by (as Schnitz astutely pointed out) an ICU consult. I would also start the kid on antibiotics, covering broadly since this is, after all, his heart we are talking about. Now I’m going to go and try to quell my paranoia about having missed something critical by eating chocolate pudding. Grossed myself out with that vanilla comment… but still want pudding.

    -Raul

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