PERICARDITIS, MYOCARDITIS AND CARDIOMYOPATHIES IN CHILDREN Flashcards
Pericarditis
Definition: ___________ or ___________ of the
___________.
Infection or inflammation of the
pericardial space.
• 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
Aetiology of pericarditis
• __________
• __________
• __________
• Idiopathic
• Infectious
• Non-infectious
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
Infectious
•_________ pericarditis- commonest infectious cause of pericarditis in children.
Viral
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
Common bacterial organisms in pericarditis
•______________
•__________________
• Neisseria meningitidis
• Streptococcus pneumoniae
• Others: Mycobacterium tuberculosis, pseudomonas
aeruginosa
• Staphylococcus aureus
• Haemophilus influenzae
Aetiology (rare) infectious
• Fungal - ____________
• Parasitic- _____________
Histoplasma
Echinococcus
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.
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
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
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
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
Size of pericardial effusion
Physiologic/trivial <___mm
Mild <___mm
Moderate _____mm
Large >____mm
5
10
10-20
20
Complications of pericarditis
• ____________
• Cardiac __________
• _______________
• ____________ pericarditis-
• Recurrence
• Cardiac tamponade
• Arrhythmia –
• Constrictive pericarditis-
Constrictive pericarditis-
– Characterised by a _________, adherent
pericardium that __________________ and
limits chamber _________ and maximal __________ volumes.
thickened
restricts ventricular filling
expansion ;diastolic
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
