MYO,ENDO,PERI

Question 1

What is myocarditis, what does it present with, etiology, phases, TT

Answer 1

Myocarditis:
- inflammation of myocardium, cardiomyocyte destruction
-history of fever, myalgias, N+V+,…(post-illness)
- Viral most common (COxsackie B&A, Parvovirus B19, EBV,CMV,…
-Bacterial, immunopathic ( post-viral,IBD, SLE, irradiation,drugs…)
- chronic type: lymphocytic giant cell
- Acute phase:viral replication
-Subacute phase: AB formation
-Chronic phase: fibrosis, dilatation, contraction dysfunction, HF
Presents with:
-chest pain
-arrythmia
-HF
-no symptoms
-dyspnea
-fever/malaise
-tachycardia and gallop

Lab tests: Troponin,Ck-MB, BNP, isolation virus, serology
ECG: tachy, ST-T changes (straight face steep T wave), small QRS voltage, A-V block
Cardiac magnetic resonance (hyperemia, edema heart)
Xray: cardiomegaly, incr.pul perfusion
Doppler/Echo: decr. EF, DCMP

TT:

• underlying disease (anti-viral usually too late, steroids for rheumatic diseases,..)
• BEDREST
• depends : HF(ACE, FUROSEMIDE)
• LV FAILURE (B-BLOCKERS)
• Arrhythmias: amiodarone

If serious decompensation: ECMO,…

Question 2

Heart failure in children

Answer 2

Warm&dry: normal filling pressure, good perfusion
Warm&wet: most common, elevated filling pressure, good perfusion
Cold&wet: elevated perfusion pressure and poor perfusion
Cold |&dry: worst- normal filling pressure & poor perfusion

Question 3

Pericarditis what does it present with, etiology, phases, TT

And complications

Answer 3

Fluid in pericardial sac mild-severe

• dull, achy, pressure
• worse lying down
• dyspnea,cough
• muffled heart sounds (friction rub)
• pulsus paradoxus ( drops >10mmHg in inspiration)
• HF

Etiology:

• Viral: same as myo + TB
• post surgery
• trauma
• SLE,…
• drugs
• kidney failure(uremic)

ECG: STT elevation happy face

• generalised distribution
• PR depression
• rarely arrythmias
• electrical alternans( if heart swings)

CMR,Xray,ECHO,…

TT: NSAIDS, AB, diuretics, prednisone,… depends on cause

complications: constrictive (calcified), tamponade –> TT pericardiectomy

Question 4

Infective endocarditis what is it, Aetiology, RF

Answer 4

Infection of endothelium &valves , vegetations of valves

• strep viridans (abnormal valves, progressive)
• staph.aureus (normal valves, rapid destruction)
• 5-10% cultures neg
• HACEK (teeth)

RF: prosthetic devices, cyanotic CHD, history of IE

• FEVER, NEW HEART MURMURS,
  -palor, petechiae
  -hematuria
  -HF
  Arthralgia,myalgia
  -splenomegaly (excess function)
  -signs of bacterial emboli ( osler’s nodes)

BLOOD CULTURES: bacteriemia
ECHO trans-thoracic; vegetations

ESR/CRP HIGH, XRAY,…

TT 4-6 w

• strep: Pennicillin/CTRX +gentamicin
• SA: Oxacillin +gentamicin
• surgery: refractory, complications, funga
  l. ..

Complications:
rupture valve, emboli, myocardial abscesses, CNS emboli most dangerous,

nb: prophylaxis (with AMOXI) only if invasive dental surgery, surgical procedures in infected areas IN PATIENTS WITH cyanotic CHD, prosth.valves, +ve history.

Question 5

Fever prolonged causes

Answer 5

Infective:
• Localised infection
• Bacterial infections: e.g. typhoid, Bartonella
henselae (cat scratch disease), Brucella
• Deep abscesses: e.g. intra-abdominal, retroperitoneal,
pelvic
• Infective endocarditis
• Tuberculosis
• Non-tuberculous mycobacterial infections:
e.g. Mycobacterium avium complex
• Viral infections: e.g. EBV, CMV, HIV
• Parasitic infections: e.g. malaria, toxocariasis
Non-infective:
• Systemic juvenile idiopathic arthritis (SJIA)
• Systemic lupus erythematosus (SLE)
• Vasculitis (including Kawasaki disease)
• Inflammatory bowel disease
• Sarcoidosis
• Malignancy: e.g. leukaemia, lymphoma,
neuroblastoma
• Macrophage activation syndromes: e.g. HLH
(haemophagocytic lymphohistiocytosis)
• Drug fever
• Fabricated or induced illness.

Question 6

Kawasaki

Answer 6

CELLULAR AND HUMORAL RESPONSE

• probably RNA virus
• genetic susceptibility
• forms a vasculitis of VESSELS, necrosis, stenosis

6months-4 yo (young children)
-incomplete more common

Diagnosis:
fever +4 criteria

fever with CALS +4 criteria

Atypical: fever + 1/2 criteria

• FEVER >5D, IRRITABILITY (early)
• conjunctivitis (early)
• stomatitis/strawberry tongue (early)
• cervical lymphadenopathy (early)
• arthritis
• abdominal pain
• rash (2-3 d)
• erythema of hands and feet (2-3d)

-desquamation (21 d)
CALS - 12-28d (2nd week)

Other signs: multi organ changes: rhinitis, V+D+, liver dysfunction, jaundice, arthralgia, CNS (aseptic meningitis), infl. of BCG scar

Lab values: ESR,CRP, high platelets (in subacute phase), incr. igE, liver enzymes,

DO ECG: arrythmias, myocarditis,…
ECHO (if no cals, @ diagnosis, 2weeks, 6-8 weeks) (if cals, every 7d, follow up every 6m.

Stages acute (1-2weeks) , subacute, resolving

RF for CALS formation: male, perimyocarditis, fever>10d, young, decreased PL (aggregated)

TT:

IVIG by 10th day 2g/kg 9 days
Aspirin @high dose:80-100mg/kg/d
Aspirin lower until no cals @8w
DONT GIVE ASPIRIN IF HAD INFLUENZA OR VZV
\+clopidogrel if aneurysms/or PL low

DD:
scarlet fever (stomatitis)
SJS (fever + rash)
Staph scalded skin syn ( squalms)
JRA (arthralgia)