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1、臨床病理討論會小兒科：盧俊維醫師放射科：吳金珠醫師病理科：蕭正祥醫師A 10 y/o girlChief complaint:Chest discomfort, vomiting and dry cough for one dayBrief HistoryGrowth & development:Weight: 22 kg (3rd-10th percentile)Height: 130 cm (25-50th percentile)Development milestone: within normal limitPast historyHand-foot-mouth disease in
2、1998Frequent URI and fever during childhoodNo drug or food allergyBrief HistoryFamily history:Her sister had fever and URI recently. Present IllnessFever and bilateral hand arthralgia attack once 1 month agoChest discomfort and cough since 9/11 afternoon, 2001Visit LMD and URI was toldVomiting and c
3、hest tightness on 9/12 0 AM and 5 AMPresent Illness9/12 morning, visit LMD again, ECG showed arrhythmiaRefer to 亞東 hospitalPresent IllnessFindings at 亞東 hospital Clear consciousness, ill-looking, pallor appearance, no cyanosis Irregular heart beat EKG: VPC bigeminyPresent IllnessLab. findings at 亞東
4、hospital WBC 9000/mm3, Hb 13.5 g/dl BUN 11 mg/dl, Cre 0.6 mg/dl GOT 25 U/L, CK 665 U/L, CK-MB 175 U/LPresent IllnessEchocardiogram at 亞東 hospital Multiple small VSDs, muscular trabecular type, at apex LV dyskinesia, LVEF 60-70% Mild TR, mild MRPresent IllnessManagement at 亞東 hospital Lidocaine iv dr
5、ip Dopamine 10 mg/kg/min Refer to NTUH (2pm)Physical ExaminationPhysical findings at NTUH Consciousness: lethargic, acute ill-looking T/P/R: 37/140/25 BP 80/46 SaO2 97% HEENT: pale conjunctiva anicteric sclera mild cyanotic lipPhysical Examination Neck: jugular venous engorgement Chest: bilateral ba
6、sal rles Heart: irregularly irregular beats, distant heart sound no murmurPhysical Examination Abdomen: no hepatomegaly hypoactive bowel sound Extremities: freely movable cold and cyanotic poor capillary refillingInitial Lab DataCBC: WBC Hb Hct Plt 37.2 % 160 K Seg 82.4%, Lym 13.8%, Eos 0.1%BCS: BUN
7、 Cre Na K Cl Ca Initial Lab DataVBG: pH pCO2 pO2 HCO3 BECardiac enzyme: CPK(U/L) CK-MB Troponin I (ng/ml) CRP: 0.53 mg/dl Initial Lab DataEKG (9/12): Initial Lab DataEKG (9/12): Initial Lab DataEKG (9/12): Initial Lab DataEchocardiogram (9/12):LV enlargementLVEF 45%Muscular VSDMild MR, TR, PR Echoca
8、rdiogram (9/12)Course and TreatmentManagementFor cardiogenic shock: Dopamine, Dobutamin, Primacor, LasixFor ventricular arrhythmia: Amiodarone, Lidocaine, MgSO4For myocarditis: IVIG, Consider extracorporeal membranous oxygenator (ECMO) supportCourse and Treatment9/12 5pm (3 hr after admission)Progre
9、ssive hypotensionSudden onset of coma, BP drop (pulseless)EKG: ventricular tachycardiaStart CPR (40 min)Start ECMO, transfer to SICUEKG (9/12, 5 PM)Course in SICUECMO settingV-A ECMO: 15 Fr Rt femoral artery, 19 Fr Rt femoral vein by cutdownFlow: 2000 ml/minMean BP: 70 mmHgUrine output: 1.72 ml/kg/h
10、rEchocardiogram (9/13)Course in SICUVT persistent despite of cardioversion, Lidocaine, Amiodarone, MgSO4 9/12 9/17: ECMO 5 daysPoor LV functionPersistent lung edema (CXR, clinically)TnI slowly decreaseA-line flatten, no pulsatile wave formCourse in SICUEndomyocardial biopsy (9/14)Mild to moderate pe
11、rivascular and interstitial lymphocyte infiltrationFoci of myocyte degeneration Interstitial edemaNo giant cell Compatible with acute myocarditisCourse in SICULA drain (9/17): To decompress LV, avoid thrombosisLA dome cannulation connecting to FV cannula ECMO FALAP: 22 mmHg 10 mmHgEchocardiogram (9/
12、17)Course in SICU9/18, 4am Acute thrombosis at LA cannula and ECMO circuit poor flowCPR for 30 min. and emergent re-set ECMO tubing Cons. After CPR: E1M1VTLight reflex (+)Course in SICU9/19, 8am: gross hematuria and ECMO tube thrombosis reset ECMOProgressive dilated pupils, no light reflex, suspecte
13、d hypoxic encephalopathyRemove ECMO on 9/23 (10th day)Lab data9/129/139/149/159/169/17TnI31.962.41007437.3CK104091242342126759138647026CK-MB196368687403207101Cre0.630.590.560.50.470.51Bil1.240.510.651.361.51.35Lab DataLab DataSerology study;Mycoplasma pneumonia IgM: (9/12) positive, (9/21) negativeO
14、ther virology study: all negative Coxsackie A, Coxsackie B1-B6, CMV IgG & IgM, Enterovirus 70, Influenza A & BLab DataCulture:Throat swab (9/12): Staphylococcus aureusNasal swab (9/12): Staphylococcus aureus, Viridans streptococciBlood (9/19): Staphylococcus epidermidisDiscussionDiagnostic approach:
15、 Cause of chest pain in childrenIdiopathic: 12-45%Costochondritis: 9-22%Musculoskeletal trauma: 21%Cough, asthma, pneumonia: 15-21%Psychogenic factors: 5-9%GI disorders: 4-7%Cardiac disorders: 0-4%Diagnostic approachHx: cough, vomitingPE: hypotension jugular venous distention tachycardia irregular h
16、eart beat basal rles poor peripheral perfusion Cardiovascular compromise Diagnostic approachFlu-like illness, arrhythmia, cardiovascular compromise Acute myocarditis highly suspectedD/D: Dilated cardiomyopathy Anomalous left coronary artery Chronic tachyarrhythmia Pericarditis Diagnostic approachEKG: VPC bigeminy, ventricular tachycardiaST-segment changeElevated cardiac enzymeEchocardiogram: marked LV dyskinesiaEndomyocardial biopsyLymphocyte infiltrationMyocyte degeneration Acute myocarditis co
