PERICARDITIS, MYOCARDITIS AND CARDIOMYOPATHIES IN CHILDREN Flashcards by Iseoluwa Ojo

Pericarditis

Definition: ___________ or ___________ of the
___________.

Infection or inflammation of the
pericardial space.

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• Normally there is _________ ml of pericardial fluid in the pericardial space.

Pericarditis can result in increased _________ in the pericardial space (pericardial _________).

10-50ml

fluid accumulation

effusion

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Aetiology of pericarditis

• __________
• __________
• __________

• Idiopathic
• Infectious
• Non-infectious

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Aetiology of pericarditis

Infectious
• Viral pericarditis

•_____________ (most common viral cause)
• Other viruses – Echo, Adeno, Influenza.
Mumps, Varicella, Epstein-Barr, CMV, Viral
hepatitis B, HIV, Human herpesvirus 6,
Parvovirus B19.

Coxsackievirus B

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Infectious
•_________ pericarditis- commonest infectious cause of pericarditis in children.

Viral

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Bacterial pericarditis: Primary infection is (common or rare?).

• Pathogenesis
–_______________ of an infection from an
adjacent pneumonia or empyema.
–distant infection can ___________ seed the
pericardium

Rare; direct extension

haematogenously

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Common bacterial organisms in pericarditis
•______________
•__________________
• Neisseria meningitidis
• Streptococcus pneumoniae
• Others: Mycobacterium tuberculosis, pseudomonas
aeruginosa

• Staphylococcus aureus
• Haemophilus influenzae

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Aetiology (rare) infectious

• Fungal - ____________
• Parasitic- _____________

Histoplasma

Echinococcus

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CLINICAL MANIFESTATIONS of pericarditis
• Often preceded by _______.
• ______ (low to mod) and __________.

• Pericardial _________ (cardinal sign)-
• _________,__________.
• _______ cough, anxiety, fatigue.
• Bacterial pericarditis presents as ____________.

URTI.

Fever ; Chest pain.

Pericardial friction rub

Tachycardia ; tachypnoea.
Dry ; sepsis.

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Pericarditis:

Chest pain is (dull or sharp?) & (variable or constant?). Radiates to _______,_______, and _________. ________ and ___________tends to ease the pain, while ___________ and ___________ worsens it.

Sharp; constant

neck, shoulders ±abdomen

Sitting up and leaning forward

lying down and breathing deep

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Pericardial friction rub (cardinal sign)-
–________,______ -pitched, to-and-fro sound caused by the _______________________ during cardiac motion.

Loudest when the patient is _________ and ___________, the sound is heard best in the 2nd to 4th intercostal spaces along the left sternal border or the midclavicular line.

scratchy, high

inflamed pericardial surfaces rubbing together

upright and leaning forward

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Pericardial effusion
• Pericardial effusion: Inflammation of the
pericardium secondary to infection leads to
________________________ to proteins and
inflammatory cells, and _________________
between the visceral and parietal layers.
• This fluid can be serous, serosanguinous, pus, fibrinous, caseous, lymph or blood.

increase in permeability

fluid accumulates

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Pericardial effusion

Onset: can be _______,_______, or ____________

Distribution: ____________ or ____________

Composition :
Transudate- e.g. _________
Exudate – e.g. ______

Acute , Sub-acute, or Chronic (>3 months)

Circumferential or Loculated

serous fluid; pus

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Size of pericardial effusion

Physiologic/trivial <___mm
Mild <___mm
Moderate _____mm
Large >____mm

5
10
10-20
20

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Complications of pericarditis
• ____________
• Cardiac __________
• _______________
• ____________ pericarditis-

• Recurrence
• Cardiac tamponade
• Arrhythmia –
• Constrictive pericarditis-

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Constrictive pericarditis-
– Characterised by a _________, adherent
pericardium that __________________ and
limits chamber _________ and maximal __________ volumes.

thickened

restricts ventricular filling

expansion ;diastolic

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Presence of continued heart failure
without a large cardiac silhouette suggests
__________

constriction

Cardiac tamponade

• Cardiac tamponade is a life-threatening, slow or rapid __________ of the heart due to the ________________ of fluid, pus, blood,
clots or gas as a result of inflammation,
trauma, rupture of the heart or aortic
dissection.

compression; pericardial accumulation

The clinical features of cardiac tamponade are caused by reduction of _____________and elevated ____________.

It can lead to ______________ (weak
peripheral pulses, cool and clammy
extremities.

cardiac output

venous pressure

obstructive shock

Clinical signs of cardiac tamponade
•________
•____________
•___________________ (an exaggerated fall in SBP with inspiration)
• Raised _____________, hepatomegaly
•____________________ heart sounds
• Decreased electrocardiographic voltage with electrical alternans
• Enlarged globular cardiac silhouette on chest x-
ray.

Tachycardia; Hypotension

Pulsus paradoxus; jugular venous pressure

Absent, distant or muffled

Beck’s triad in cardiac tamponade

• ___________
• Elevated systemic venous pressure, often
with raised ______
• __________________

• Hypotension
• Elevated systemic venous pressure, often
with raised JVP
• Muffled heart sounds

Diagnosis of acute pericarditis
• Presence of at least ____ of the following
four criteria:
1. Characteristic ________
2. Pericardial ________
3. Characteristic ___________ changes
4. new or worsening ________

two

chest pain; friction rub

electrocardiographic

pericardial effusion.

Prognosis
• Good for _______ or _________ pericarditis.
• A mild idiopathic effusion is usually
asymptomatic has a good prognosis.
• ________________ effusions (>10 mm) may worsen, and especially severe effusions may evolve towards cardiac tamponade in up to one-third of cases.

acute viral or idiopathic

Moderate to large

Myocarditis
– Definition: inflammatory disease of the _____________[.
– Myocarditis can be acute, subacute, or
chronic and may either involve _______ or _______ areas of the myocardium.
• It is (common or rare?) in children.

heart muscle cells

focal or diffuse

Rare

Aetiology of myocarditis • Infection – Commonest cause - _______ infections • _____________ • Medications • Chemicals • Radiation

viral Acute rheumatic fever

Aetiology of myocarditis • Infection – Commonest cause - _______ infections • _____________ • Medications • Chemicals • Radiation

viral Acute rheumatic fever

Pathophysiology of myocarditis- phases 1. ________ injury 2. Injury related to the ensuing ________________________ responses 3. Recovery, or transition to scar with _________.

Acute innate and acquired immunologic DCM

Clinical presentation of Myocarditis • The clinical presentation is extremely varied, ranging from ___________ to _____________ • A high index of suspicion is therefore crucial

asymptomatic to sudden unexpected death.

Clinical presentation of myocarditis •____________ is the most common presenting picture in all ages. – Older children - Hx of ______,______, exercise intolerance and lack of energy, malaise, _____-grade fever, arrhythmia, _______ and gradual onset of CCF. – Newborns –____________, lethargy, periodic episodes of ______, ________ , hypothermia, tachypnea, anorexia, failure to thrive, diaphoresis

Heart failure URTI ; chest pain; low; cough Irritability; pallor ; fever

Complications of myocarditis • ___________ • ___________ • ___________ • Further decrease in ventricular function • ___________ cardiomyopathy

Complications • Arrhythmia • Congestive heart failure • Thromboembolism • Further decrease in ventricular function • Dilated cardiomyopathy

Prognosis of myocarditis • Viral myocarditis – ______________ of ventricular function -50% of patients. – Some develop _________ myocarditis (ongoing or resolving), – some develop ___________________. – Those who develop dilated cardiomyopathy may require a heart transplant.

Complete recovery chronic; dilated cardiomyopathy

Cardiomyopathy • Definition: Abnormalities of the __________ unexplained by abnormal loading conditions or congenital heart disease.

ventricular myocardium

TYPES OF CARDIOMYOPATHY • list 4

TYPES OF CARDIOMYOPATHY • Dilated Cardiomyopathy: • Hypertrophic Cardiomyopathy • Restrictive cardiomyopathy e.g. endomyocardial fibrosis. • Arrhythmogenic right ventricular cardiomyopathy

Commonest cardiomyopathy is ???

DCM

DILATED CARDIOMYOPATHY • Definition: A progressive disease of heart muscle that is characterized by ———————————- (mostly _______) and _________ dysfunction with or without CCF.

ventricular chamber enlargement left; contractile

Pathogenesis of myocardial damage in DCM • Major factors – preceding ____________ – ______________ – underlying ____________________.

viral myocarditis Autoimmunity genetic predisposition

Pathophysiology of DCM • Decrease ____________ • ___________ of the heart and an increase in the ____________ volume caused by increased preload. • Inflammatory mediators, such as cytokines and adhesion molecules, as well as apoptotic mechanisms, are activated. • The progressive increase in LV end-diastolic volume increases LA, pulmonary venous, and pulmonary arterial pressures, resulting in increasing hydrostatic forces. • These increased forces lead to _________ and __________. • Without treatment, this process may progress to death.

myocardial function Enlargement; end-diastolic pulmonary edema and CCF

Clinical manifestations of DCM •__________ onset. •________ onset in a quarter of cases. • Hx of previous _______ in half of cases.

Insidious; Acute viral illness

Clinical manifestations of DCM Initial • ———— • ———— feeding • Irritability • ———— of breath • ———— • Sweating • Fatigability • Failure to ———— • Decreased ————

Clinical manifestations Initial • Cough • Poor feeding • Irritability • Shortness of breath • Pallor • Sweating • Fatigability • Failure to gain weight • Decreased urine output

Clinical manifestations of DCM Others • _______ pain • Palpitations • Orthopnea • Hemoptysis • Frothy sputum • Abdominal pain • Syncope • Neurologic deficit

Chest

Complications of DCM • _______________ •__________ • ____________ • Pulmonary or systemic emboli from intracardiac thrombi.

Ventricular arrhythmia Syncope Sudden death

Prognosis of DCM • 1/3 recover completely • 1/3 stabilize • 1/3 progressively worsen • 5 year survival is ______%. • If the cause of DCM is ___________, children are more likely to improve and have a better outcome than children with other causes of DCM.

40-50 myocarditis