Hilary Ong MD, Children’s National Medical Center

The Case:
10 week old ex-FT female with no significant PMH presented with fever Tmax 101 and vomiting for 3 days and 1 day of intermittent increased work of breathing. Had sick contacts at home with URI symptoms, but the patient had no cough or congestion. Was tachycardic and tachypneic with clear lungs, but mild subcostal retractions. The patient was fussy throughout their ED stay but consolable. Labs revealed a mild leukocytosis with clean urine and a non obstructive abdominal xray per radiology.

Here’s How You Answered Our Questions:

Discussion:

Sometimes life is not as straightforward as you think it is! We were all in agreement that this baby had something going on, but at this point can not be pinpointed. Thus, we all needed more information in the form of labs and imaging. The set of labs and imaging requested by both fellows and attendings were on par. Dr. Prieto stated that often times she gets the complete metabolic profile in babies rather than the simple basic metabolic profile to ensure she is not missing any possible liver involvement that may point her down the metabolic path. As Dr. Chapman pointed out, the utility of a KUB in an infant where obstruction is suspected is not helpful and should be avoided, rather a 2 view abdominal radiograph should be obtained. Many felt at this time that the most pressing issue from an emergency perspective was to ensure this was not a surgical abdomen so imaging was geared appropriately.

Dr. Zaveri reiterated the importance of giving our radiology colleagues as much clinical picture as possible when placing orders because often times studies can be tailored appropriately based on the pre test probability we have. He stated that occasionally, if suspicion is high enough, radiology will do the 2 view AXR as part of the UGI series thus expediting the patients care. However, this picture was not quite that clear. Was the mild respiratory distress coming from a distended abdomen thus decreasing TLC, splinting from pain, or a cardiac/lung issue.

Many of us have palpitations when it comes to treating an infants with antibiotics without a clear source, especially when we have not done the entire work up in this age group. Drs. Lindgren and Guse brought up that if you choose to treat, you must do the LP even if suspicion is low as all our evidence at this time suggests so and any deviation would not be evidence based medicine. Luckily, many of us felt the child was stable enough at this time to hold on antibiotics and continue to gather more information while continuing to defer the LP.

Finally, to our surprise, the images of the abdominal xray were revealed and read as non obstructive by radiology! Our estute Dr. Donnelly did note that there appears to be some mild cardiomegaly on the portion of the film that was taken and stated her next step would be to obtain a dedicated chest xray to delve a little deeper down that path. However, the majority, of us felt the xray looked too abnormal for our comfort especially with what appears to be some sort of air fluid level despite the initial radiology wet read thus resulting in many peoples decision to continue down the abdominal brick road and obtain an UGI series.

Denouement:

The abdominal exam showed distention of the stomach bubble without evidence of small bowel obstruction, however, incidentally showed an enlarged cardiac silhouette. The ED POCUS team was available and able to perform a bedside echocardiogram. It showed an enlarged left ventricle with poor function and without effusion.

Cardiology was consulted and confirmatory echo revealed a poor ejection fraction. The patient was ultimately admitted to the CICU for heart failure secondary to presumed viral myocarditis. She ultimately did well and was discharged home on heart failure medications and close follow up.

Acute myocarditis is one of the most challenging diseases to diagnose and treat. The true incidence is unknown but viral etiologies are by far the most common cause. Patients can range from being asymptomatic to non specific EKG changes to sudden cardiac death.

Shauer A, Gotsman I, Keren A, Zwas DR, Hellman Y, Durst R, Admon D. Acute viral myocarditis: current concepts in diagnosis and treatment. Isr Med Assoc J. 2013 Mar; 15(3):180-5.

https://www.ncbi.nlm.nih.gov/pubmed/23662385

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