Pediatric Case Challenge: Alarming Symptoms in a Toddler Who Had Myocarditis and Recently Immigrated

Shah Azmoon, MD; Matthew Budoff, MD; David Atkinson, MD


January 17, 2023

Physical Examination and Workup

Upon physical examination, the patient is in no apparent distress. The child is not cyanotic, and she is noted to be in the 50th percentile for height and weight. Her vital signs, including an oxygen saturation level of 98% while breathing room air, are all normal. The cardiac examination reveals a visible and lateralized point of maximal intensity, a normal rate and rhythm, a fourth heart sound, and a II/VI holosystolic blowing murmur of mitral regurgitation. Her breath sounds are clear bilaterally. No hepatomegaly is noted on the abdominal examination, and symmetric normal amplitude pulses are found in all extremities.

Chest radiography is performed (images not available) that is significant for cardiomegaly, without any evidence of acute venous congestion. An electrocardiogram (ECG; tracing not available) reveals sinus tachycardia, Q waves in leads I and aVL, and inferior ST-segment depression with T-wave inversion that is suggestive of ischemia in the inferolateral distribution with repolarization abnormalities.

The pediatrician refers the patient to the pediatric ED of an affiliated hospital, where an initial transthoracic echocardiogram (TTE) reveals a dilated left ventricle with an ejection fraction of 15%, the presence of a left ventricular thrombus and spontaneous contrast, and a small pericardial effusion. The patient is admitted for anticoagulation therapy and further workup of her cardiomyopathy, which includes a gallium scan with an unremarkable result and mildly elevated pulmonary artery (PA) pressures detected on right heart catheterization. A repeat TTE obtained during the course of the admission shows resolution of the thrombus and an ejection fraction of approximately 25%; however, the TTE is not able to appreciate the continuous course of the coronaries.

The patient is referred for cardiac CT angiography (CCTA) for better delineation of her coronary anatomy. The CCTA images are obtained using low-dose protocols, with an estimated radiation dose of 1 millisievert (Figure 1, Figure 2).

Figure 1

Figure 2


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