1. +
CRITICAL APPRAISAL PEARLS
IMMUNIZATION
CASE II
DR Saptharishi L G

2. +
Diagnostic Issues

3. +
Does it fit into AFM??

Libermann et al (1991)

Clinical & Echocardiographic criteria for ‘Acute Fulminant
Myocarditis’


Developed acute and severe heart failure during this illness

Evidence of Left ventricular dysfunction on Echo (EF< 40%)


Recent history of viral prodrome with fever lasting < 2 weeks
No previous or family history of cardiomyopathy
Acute heart failure:

Fatigue, breathing difficulty or edema developing during a 1-2 day
period and within 7 days prior to hospitalization

4. +
Non- Obstructive TAPVC ??
Why not ??

Short history with a ‘not-so-impressive’ fever

CXR – Bilateral white-out

ECHO (on D1 hospital stay)

RA & RV grossly dilated

12 mm ASD with R L shunt

Mild TR and PR

Almost all ABGs (except one) showing PaO2 < 80

Clinical SpO2 – fluctuating; ?Pulmonary reactivity

5. +
What we could have done?

12 lead ECG

ECHOCARDIOGRAPHY

Caveats of echocardiography in TAPVC

One of the most difficult-to-diagnose conditions on ECHO

Serial Echo evaluations required – most often

Specific expertise in pediatric echocardiography required
CLARIFICATIONS REGARDING ECHOCARDIOGRAPHY
• Consultant Echo could have been considered in this case?
• Echo done for myocarditis ? Information regarding
contractility/ Ejection fraction ? If normal, how does that
correlate with our clinical picture?

6. +
Positives

SEPSIS: Points in favor

High counts

Pneumonia (bilateral infiltrates) + Myocarditis + elevated OT/PT

Nosocomial sepsis – COEXISTING?

Outside hospital stay – 1 day



Multi-drug resistant Acinetobacter
Isolated from Blood c/s within 48 hours of admission
What precipitated the illness in the first place??

Rickettsial infection / Leptospirosis ruled out

Viral causes more likely?

7. +
What does available literature say?
1. Coxsackie virus
2. Adenovirus
3. Enteroviruses
Can produce this kind of a clinical presentation
Most important causative agents for Acute Fulminant Myocarditis

8. +

9. +

10. +
How do elevated AST/ALT fit in??

11. +
Management Issues

12. +
Management of shock

First documentation of CVP at 26 hours of hospital stay

Refractory to most measures (Fluid + Ionotropes)

Cause of refractory shock ?

Most precipitating causes ruled out

Hydrocortisone shock dose given

Acute Fulminant Myocarditis
Most of the recent reviews on Myocarditis in
Infants and neonates – report use of LVAD or
ECMO for refractory cardiogenic shock
secondary to Acute fulminant Myocarditis

13. +
Is IVIG the answer to
MYOCARDITIS ??

14. +
No evidence to support routine IVIG
or steroids

15. +

16. +
Post Mortem Biopsies

Was Myocardial biopsy considered?



AHA recommendation in all clinically suspected myocarditis*
EMB Vs Cardiac MRI
Was any other biopsy carried out? If yes, what do the findings
suggest?

17. +
Summary of queries

Was TAPVC considered as a possibility in this child?

Why was 12 lead ECG not considered?

How do we explain the echocardiographic picture in the setting
of AFM ? (Apparently normal ejection fraction)

Shock management – Comments?

Post mortem biopsy reports