Pediatric Myopericarditis Presenting to the Emergency Department as Chest Pain

Abstract

Objectives: Myopericarditis is a newly described entity that is primarily a pericardial syndrome with elevated cardiac enzymes that has been seen with increasing frequency in our pediatric intensive care unit. For this reason, we performed a retrospective cohort analysis with a goal of establishing differences between myopericarditis and myocarditis that could lead to proper diagnosis on emergency department presentation.Methods: A database query was performed and identified patients over a 9-year period, and clinical data, laboratory data, and cardiac studies were extracted and analyzed from the electronic health record.Results: A total of 36 patients were identified with the discharge diagnosis of myopericarditis and 22 with myocarditis. The median age for myopericarditis patients was 16.2 years, and 97% were male. The median initial troponin was 7.1 ng/mL, the peak was at 16.6 ng/mL, and 58% had ST changes on electrocardiogram. The median length of stay for myopericarditis patients was 1.7 days, and 50% were discharged home on nonsteroidal anti-inflammatory medication. Compared with myocarditis, myopericarditis patients were older, had a higher incidence of chest pain, and were less likely to have fever, vomiting, abdominal pain, upper respiratory infection symptoms, chest radiograph abnormalities, or T-wave inversion (P < 0.05). Myopericarditis patients also had lower Pediatric Risk of Mortality version 3 scores, B-type natriuretic peptide levels, and higher left ventricular ejection fractions on admission (67% vs 41%; P < 0.05). A classification model incorporating initial left ventricular ejection fraction, B-type natriuretic peptide, electrocardiogram, and chest radiograph findings distinguished myopericarditis from myocarditis with correct classification in 95% of patients.Conclusions: Myopericarditis is a relatively common cause of chest pain for patients admitted to the pediatric intensive care unit, presents differently than true myocarditis, and carries a good prognosis.

Subclinical Arrhythmias and Conduction Disturbances in Children with Myopericarditis: A 24-hour Holter Monitorization Study

“… 3 , 5 In the literature, there is a prominent male predominance. 5 , 8 Also in our study, 74% of the patients was male.…”

“…Depending on ECG findings, Başar et al 5 reported ventricular premature beats in 5.1%, and supraventricular tachycardia in 2.6% of 39 children. Babbitt et al 8 did not make a comment about the frequency of arrhythmias between children with myopericarditis and true myocarditis. In none of the above studies, 24-hour Holter monitorization had been performed.…”

“…The reported main complaint in children with myopericarditis is chest pain. 3 , 5 , 8 Non-specific findings such as decreased exercise capacity, palpitations, fever, or weakness may also be present. 5 Among our patients also, the most frequent symptom (100%) was chest pain and 12 had additional symptoms.…”

“…Even in the patients with very high troponin levels, the prognosis of the disease is reported to be very good and does not seem to carry an adverse prognosis. 3 , 5 Despite that, Babbitt et al 8 reported a patient who was initially believed to have myopericarditis on admission but developed deterioration and required intubation. Repeat echocardiogram 22 hours after admission found that left ventricular ejection fraction (LVEF) had decreased to 37%.…”

“…Although the clinical features of children with the diagnosis of myopericarditis had been reported in several studies, 3 - 5 , 8 the frequency of arrhythmias had not been investigated in detail among children. To our knowledge, this is the first report investigating the frequency of arrhythmias in children with myopericarditis.…”