Chest pain as a complaint warrants great concern in our adult patients, but in children it is often perceived as benign by default. Naturally, there are a number of entities that are of concern that should be considered before we jump to the “it’s costochondritis” speech with families. We have discussed several causes of chest pain in the past (ex, myocarditis, pulmonary embolism, pneumomediastinum, spontaneous pneumothorax), but one that deserves some attention now is Pericarditis.
- Pericardium has a visceral and parietal layer
- Small amount of fluid (~35mL of ultra filtrate of plasma) contained within sac normally.
- Functions to:
- Maintain orientation between great vessels and heart
- Prevent sudden dilation of ventricle during exercise/exertion
- Assist in atrial filling (negative intra-pericardial pressure)
- Acts as barrier to spread of infections from lungs to heart.
Pericarditis Recent Numbers:
- True incidence of pericarditis is likely under-estimated in children.
- Male predominance (~80%) [Shakti, 2014]
- Male adolescents constituted ~50% of this study group
- Median Age = 14.5 years (range 7 – 17 years) [Shakti, 2014]
- Pericardial drainage was performed in 17.7% of cases [Shakti, 2014]
- Generally a benign, self-limited course.
- 60% recover in 1 week.
- ~30% can develop recurrent pain.
- Readmission occurred in ~10% of cases. [Shakti, 2014]
- No therapeutic or underlying medical condition more associated with readmissions.
- Idiopathic (37%-68%) [Ratnapalan, 2011]
- Viral (ex, coxsackievirus, EPV, influenza)
- Metabolic (ex, uremia, myxedema)
- Rheumatic Disease (ex, Lupus, Rheumatic Fever) (~30%) [Roodpeyma, 2000]
- Neoplastic Disease (~10%) [Roodpeyma, 2000]
- Medication Adverse Reaction (ex, hydralazine, isoniazid)
- “Classic Triad” = fever, dyspnea, and chest pain
- Of course, that sounds like pneumonia also.
- 96% of acute pericarditis present with Chest Pain [Ratnapalan, 2011]
- Often described as sharp, but can be dull.
- Often worse with leaning backward, deep breaths, or coughing.
- Often referred pain to shoulder, epigastric region, and/or back.
- 56% presented with fever [Ratnapalan, 2011]
- Pericardial friction rub may not be heard
- Especially if there is a large effusion
- Heard best during expiration and with child leaning forward.
- ALL children in one study had abnormal ECGs [Ratnapalan, 2011]
- CXR – can be helpful, but may be normal in up to 40% [Ratnapalan, 2011]
- U/S – 82% had a pericardial effusion [Ratnapalan, 2011]
- No lab diagnoses pericarditis.
- Several can help “complete the picture” that was started by the history and physical exam and supported by ECG and U/S.
- ESR, CRP, and Troponin have all been shown to be elevated with acute pericarditis.
- First make sure there is no cardiovascular compromise (i.e., tamponade).
- Again, bedside U/S is very helpful here!
- NOT indicated for routine investigations / management. [Durani,2010]
- Do use for tamponade physiology.
- Do use if concern for bacterial pericarditis.
- Control inflammation.
- Treat infection if present!
- If bacterial pericarditis is suspected, initial treatment should include antistaphylococcal agents.
- Delayed therapy in these cases is associated with high morbidity and mortality.
- Contemplate other causes… is this uremia, is this Lupus?