COTW March 21: The Short of Breath Teenager

A previously healthy 14 year old male came in with weakness and shortness of breath. He was running in high school gym class when he felt weak and dyspneic and had to lie down. He had had some diarrhea and vomiting for the past few days and a recent cold.

Exam and work-up:

HR 107, BP 82/61, O2 90%, RR 30, Oral Temp 97.6

Tachypneic, tachycardic, +bilateral rales with L > R, +Diaphoresis

WBCs: 15.8, Neutrophils 83%

Hb/Hct: 15.7/47.5

Glucose 222

Creatinine 1.18

Lactic Acid: 6.4

VBG pH 7.26 pCO2 50

AP CXR

Sepsis?

Patient given Antibiotics, 1L NS, 6L Oxygen Non Breather, but began to decompensate, bradying down, altered and lethargic. Patient was intubated and had peri-intubation arrest with CPR and code epi, ROSC, and started on epi drip.

A bedside ultrasound was performed.

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The bedside Echo showed global hypokinesis with plethoric IVC consistent with acute congestive heart failure. Note that if you thought this otherwise healthy pediatric patient was septic, his ECHO was not consistent with that diagnosis.

Troponin and BNP were resulted.
Trop: 15.3
BNP: 8

The patient was diagnosed with fulminant myocarditis and transferred to an appropriate referral center, where he was placed on ECMO for 3 days and made a full recovery.