Pediatric Myocarditis & Pericarditis: Symptoms, Treatment, Emergency Department Management & Care | EB Medicine

Myocarditis And Pericarditis In The Pediatric Patient: Validated Management Strategies

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.

*NEW* Quick Search this issue!

Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
    1. Myocarditis
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Primary Survey
      1. Perform Pericardiocentesis For Cardiac Tamponade Or Large Pericardial Effusion
    2. History
    3. Physical Examination
  9. Diagnostic Studies
    1. Myocarditis
      1. Electrocardiography
      2. Chest Radiography
      3. Troponin
      4. Inflammatory Markers
      5. Echocardiography
      6. Additional Studies
        • Microbiologic Studies
        • Brain Natriuretic Peptide
        • Other Laboratory Investigations
        • Cardiac Magnetic Resonance Imaging
        • Endomyocardial Biopsy
    2. Pericarditis
      1. Electrocardiography
      2. Chest Radiography
      3. Troponin
      4. Inflammatory Markers
      5. Echocardiography
      6. Pericardiocentesis
      7. Additional Studies
        • Microbiologic Studies
        • Brain Natriuretic Peptide
        • Other Laboratory Studies
        • Cardiac Computed Tomography/Magnetic Resonance Imaging
  10. Treatment
    1. Myocarditis
      1. Supportive Therapies – Diuretics, Cardiac Support, And Antidysrhythmic Medications
      2. Immunosuppressive Agents
      3. Intravenous Immunoglobulin
      4. Antivirals And Antibiotics
      5. Myocarditis Treatment Summary
    2. Pericarditis
      1. Supportive Therapies And Nonsteroidal Anti- Inflammatory Drugs
      2. Colchicine
      3. Corticosteroids
      4. Antivirals And Antibiotics
      5. Surgical Interventions
      6. Pericarditis Treatment Summary
  11. Special Populations
    1. Patients With Congenital Heart Disease Or Recent Cardiac Surgery
  12. Controversies And Cutting Edge
    1. Myocarditis
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls In The Management Of Myocarditis And Pericarditis In Pediatric Patients
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Emergency Management Of Myocarditis And Pericarditis In The Pediatric Patient
  19. Tables and Figures
    1. Table 1. Etiologies Of Myocarditis
    2. Table 2. Etiologies Of Pericaditis
    3. Table 3. Common Etiologies Of Pericardial Effusion In Children
    4. Table 4. Indications For Pericardiocentesis And Possible Complications
    5. Figure 1. Concave ST-Segment Increases In Lateral Leads (V4-V6) In Myocarditis
    6. Figure 2. Electrocardiogram Demonstrating Concave-Up ST-Segment Elevation And PR Depression With Diffuse T-Wave Inversion In Acute Pericarditis
  20. References


Myocarditis and pericarditis are inflammatory conditions of the heart commonly caused by viral and autoimmune etiologies, although many cases are idiopathic. Emergency clinicians must maintain a high index of suspicion for these conditions, given the rarity and often nonspecific presentation in the pediatric population. Children with myocarditis may present with a variety of symptoms, ranging from mild flu-like symptoms to overt heart failure and shock, whereas children with pericarditis typically present with chest pain and fever. The cornerstone of therapy for myocarditis includes aggressive supportive management of heart failure, as well as administration of inotropes and antidysrhythmic medications, as indicated. Children often require admission to an intensive care setting. The acute management of pericarditis includes recognition of tamponade and, if identified, the performance of pericardiocentesis. Medical therapies may include nonsteroidal anti-inflammatory drugs and colchicine, with steroids reserved for specific populations. This review focuses on the evaluation and treatment of children with myocarditis and/or pericarditis, with an emphasis on currently available medical evidence.

Case Presentations

A previously healthy 4-year-old boy with symptoms of chest pain, difficulty breathing, and fever is brought to the ED. His parents note that the symptoms started 1 week prior, and they are flu-like, with general malaise, muscle weakness, and episodes of vomiting. His fever started 3 days prior to evaluation, and he has developed a cough with progressive difficulty breathing over that time, as well. The child points to the left mid-chest when asked about his pain. In triage, he is noted to have a heart rate of 180 beats/min and normal blood pressure for age. He is febrile to 38.8°C, has a respiratory rate of 38 breaths/min, and an oxygen saturation of 91% breathing room air. On examination, you note a pale, ill-appearing child. You auscultate crackles in the bilateral lung bases and a gallop rhythm on cardiac examination, although heart sounds are somewhat diminished. Capillary refill is sluggish. His liver edge is palpable 3 cm below the costal margin. What are the first steps in the immediate management of this patient? What diagnostic workup should be performed? Are there any indications for immediate echocardiography and/or immediate cardiology consultation? What is the appropriate disposition for this patient?

A previously healthy 12-year-old girl presents to your ED with chest pain and fever. Her chest pain has progressively worsened over the last 5 days, and it is described as stabbing. The pain is located over the middle of her chest, without radiation, and it is improved by sitting upright and leaning forward. Fever has been present for the past 2 days and has not resolved with antipyretics. In triage, the patient had an episode of vomiting. Her vital signs are: axillary temperature, 39°C; heart rate, 120 beats/min; normal blood pressure for age; respiratory rate, 30 breaths/min; and oxygen saturation, 96% on room air. On examination, the child appears to be in significant pain. Her pulmonary examination is unremarkable. On cardiac auscultation, you appreciate a friction rub with audible heart sounds. There is no murmur or gallop rhythm, and capillary refill time is normal. She has mild tenderness in the epigastrium. What historical features and examination findings raise concern? What are the initial steps in management of this child? What diagnostic workup should be performed? What is the appropriate disposition for this patient?


Myocarditis is an inflammatory disease of the myocardium, occasionally extending to the epicardium and pericardium, which can lead to nonischemic dilated cardiomyopathy (DCM) and chronic heart failure.1 There are many causes of myocarditis, though a systemic viral illness is most commonly implicated.2 Presentation can be acute, subacute, or progressive/ chronic.3 Initial presentation often includes a prodromal flu-like illness, including respiratory and gastrointestinal symptoms.2 Specific symptoms may include cough, dyspnea, vomiting, myalgias, and significant tachycardia out of proportion to the degree of fever.4 More-severe cases may also present with heart failure, ventricular dysrhythmia, myocardial infarction, new-onset heart block, or cardiogenic shock.2 Given the variable presentation and disease course, a high index of suspicion is required. Pericarditis is an inflammatory disease of the pericardium, and it often presents with fever and chest pain.5,6 Mild cases are likely often self-limiting, so the incidence, especially in children, is unknown. More-severe cases can progress to pericardial effusion, pericardial constriction, recurrent pericarditis, or cardiac tamponade.6,7 The underlying etiology of pericarditis is quite variable and most commonly includes infection, malignancy, and rheumatologic conditions.6,7

This issue of Pediatric Emergency Medicine Practice provides an evidence-based approach to the evaluation and management of myocarditis and pericarditis in the pediatric patient, with an emphasis on recent advances in diagnosis and treatment.

Critical Appraisal Of The Literature

A literature review was performed using the keywords myocarditis or pericarditis in Ovid MEDLINER and PubMed, focusing on children aged 0 to 18 years. Well-designed randomized controlled trials and prospective and retrospective studies were included. Commonly referenced pediatric and adult studies, as well as historical publications, were also included. A search of the Cochrane Database of Systematic Reviews yielded 4 relevant publications, which were primarily comprised of adult studies.8-11 The websites of the American Heart Association (AHA) ( and the American Academy of Pediatrics (AAP) ( were searched for guidelines pertaining to myocarditis or pericarditis in children, and none were found. Commonly cited guidelines related to the diagnosis and management of pericardial diseases, published in 2004 by the European Society of CardiologyR (ESC) and revised in 2013, were reviewed.1,12,13 Canadian Cardiovascular Society (CCS) guidelines on the management of heart failure in children were also reviewed,14 as were other commonly cited guidelines related to the management of children with myocarditis.15,16 We identified 1 position statement from the ESC Working Group on Myocardial and Pericardial Disease pertaining to the evaluation of myocarditis.1

The literature on pediatric myocarditis mainly consists of case reports and series, small retrospective and prospective studies, and small randomized controlled trials, with primary outcome measures including death, transplant-free survival, and/or improvement in cardiac function. Larger well-designed randomized controlled trials are lacking, which is, in part, attributable to the rarity of such cases in the pediatric population as well as to discrepancies in the diagnosis of myocarditis.17 Myocarditis has historically been diagnosed using the Dallas criteria, which include pathologic evidence of inflammation and myocyte necrosis on endomyocardial biopsy samples.18 However, several studies have shown that the Dallas criteria are insufficient in many cases, even with adequate biopsy samples.19,20 As a result, many studies include “presumed” myocarditis or DCM, which may lead to the inclusion of etiologies distinct from myocarditis.4,21-24

Early literature on pediatric pericarditis predominantly consists of case reports describing specific infectious and systemic etiologies, with a paucity of robust studies. The literature has since shifted to focus on the role of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs).12,13,25-28 More-recent investigation has focused on the use of colchicine for recurrent pericarditis. In 2013, Imazio et al published a randomized controlled trial among adults and showed that 4 patients would need to be treated with colchicine in addition to conventional NSAID therapy in order to prevent 1 episode of recurrence.29 A subsequent Cochrane Review concluded that there is moderatequality evidence that the addition of colchicine to NSAID therapy significantly reduces recurrence.8 The data for colchicine use in children with recurrent pericarditis remains limited to 1 small retrospective study and case reports.27,30,31

Risk Management Pitfalls In The Management Of Myocarditis And Pericarditis In Pediatric Patients

  1. “This kid just has gastroenteritis.”
    Myocarditis is a challenging diagnosis to make prior to overt symptoms of heart failure, and a high index of suspicion is required. When symptoms do not fit a typical picture, further consideration should be given to alternate diagnoses. Children with myocarditis often present with a flu-like illness and tachycardia out of proportion to the degree of fever.
  2. “The troponin is negative, so my patient can’t have myocarditis.”
    Troponin levels may have sufficient sensitivity to rule out myocarditis, but the test performance depends on the cut-off level defining a positive test. Current evidence suggests that troponin I and T lack adequate specificity in cases of pediatric myocarditis. While a negative troponin is reassuring, emergency clinicians should interpret this result in the context of the cut-off value used at their facility.
  3. “I gave 60 mL/kg of intravenous fluid to a child with myocarditis, and now he’s getting worse.”
    Children with myocarditis often present in shock, which prompts aggressive intravenous fluid administration. Failure to respond to an initial fluid bolus should raise concern for a cardiogenic cause, such as myocarditis. In cardiogenic shock, poor cardiac contractility leads to the development of pulmonary edema. Clinically, patients will develop labored breathing and crackles/rales on examination. Treatment should include inotropes and intravenous diuretics, such as furosemide.
  4. “I diagnosed my patient with myocarditis, admitted her to the floor team since she was stable, and didn’t consult cardiology.”
    rompt consultation with a pediatric cardiologist should be obtained in all cases of suspected myocarditis. Admission planning should start early and in conjunction with a pediatric intensivist, as patients can decompensate quickly. If there is no pediatric intensive care unit or cardiovascular intensive care unit at your center, plans for transfer to an appropriate center should be arranged early.
  5. “My patient has myocarditis with signs of hemodynamic compromise. I’ll start her on furosemide, and hopefully she’ll turn around without inotropes.”
    While diuresis is an essential component of treatment, inotropic support should not be withheld if patients present with signs of hemodynamic instability. Peripheral venous access should be obtained promptly. Providers should aim to restore cardiac contractility when choosing a vasopressor. Milrinone is the agent of choice; however, this may not be available in all emergency departments. Epinephrine is another excellent choice, with the addition of dobutamine, if needed.
  6. “My patient was crashing, and it looked like tamponade. I performed a pericardiocentesis over the anterior chest using a 10-mL syringe and a 22-gauge needle.”
    Pericardiocentesis is a potentially life-saving procedure, and knowledge of appropriate technique is critical. Clinicians should quickly sterilize the precordium, just below the xiphoid process. If there is time, local lidocaine should be infiltrated and sedation used as tolerated. A 2.5-inch or 3.5-inch 18-gauge spinal needle should be attached to a 20-mL to 50-mL syringe and inserted at a 45° angle just below and to the left of the xiphoid process, directed towards the left scapular tip. Maintain gentle suction on the syringe while slowly inserting the needle. If promptly available, point-of-care cardiac ultrasound should be used to visualize the procedure. Continuous cardiac monitoring should be used throughout the procedure. Ectopic beats or ST-segment elevation may indicate cardiac irritation from increased needle depth insertion.
  7. “The pericardiocentesis is done, but the patient is getting worse. What could have gone wrong?”
    Complications from pericardiocentesis are common. The most common complication is ventricular puncture, which may lead to hemopericardium. Other complications include dysrhythmia, pneumothorax, coronary artery or vein laceration, diaphragmatic perforation, puncture of the peritoneal cavity, and vasovagal episodes.
  8. “The ECG doesn’t show diffuse ST-segment elevation, so my patient can’t have pericarditis.”
    Diffuse ST-segment elevation occurs in the acute phase of the disease. Children with delayed presentation or recurrent disease may have diffusely inverted T waves or low-voltage QRS complexes.
  9. “Steroids can’t hurt, right?”
    Steroids increase the risk for development of recurrent pericarditis, and they are only recommended in refractory cases, or in cases where the underlying medical condition would be treated with such therapy (eg, autoimmune disease, known giant-cell myocarditis, or eosinophilic myocarditis).
  10. “I diagnosed my patient with pericarditis and treated him with high-dose aspirin.” Ibuprofen is the treatment of choice for acute pericarditis due to the beneficial effects on coronary blood flow and the minimal side-effect profile. Although no pediatric studies have compared different NSAIDs in the treatment of acute pericarditis, aspirin use in pediatric patients should be limited to patients with pericarditis after myocardial infarction or patients with risk of thrombosis.

Tables And Figures

Table 1. Etiologies Of Myocarditis

Table 2. Etiologies Of Pericaditis


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. * Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-2648. (Position statement)
  2. * Cooper LT Jr. Myocarditis. N Engl J Med. 2009;360(15):1526- 1538. (Review)
  3. Kindermann I, Barth C, Mahfoud F, et al. Update on myocarditis. J Am Coll Cardiol. 2012;59(9):779-792. (Review)
  4. Durani Y, Egan M, Baffa J, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009;27(8):942-947. (Retrospective chart review; 62 patients)
  5. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351(21):2195-2202. (Review)
  6. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;363(9410):717-727. (Review)
  7. Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010;85(6):572-593. (Review)
  8. Alabed S, Cabello JB, Irving GJ, et al. Colchicine for pericarditis. Cochrane Database Syst Rev. 2014;8:CD010652. (Systematic review; 4 studies, 564 patients)
  9. Chen HS, Wang W, Wu SN, et al. Corticosteroids for viral myocarditis. Cochrane Database Syst Rev. 2013;10:CD004471. (Systematic review; 8 studies, 719 patients)
  10. Mayosi BM, Ntsekhe M, Volmink JA, et al. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev. 2002(4):CD000526. (Systematic review; 4 studies; 469 patients)
  11. Robinson J, Hartling L, Vandermeer B, et al. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev. 2005(1):CD004370. (Systematic review; 1 study, 62 patients)
  12. * Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2004;25(7):587-610. (Clinical guidelines)
  13. * Seferović PM, Ristić AD, Maksimović R, et al. Pericardial syndromes: an update after the ESC guidelines 2004. Heart Fail Rev. 2013;18(3):255-266. (Clinical guidelines)
  14. Kantor PF, Lougheed J, Dancea A, et al. Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines. Can J Cardiol. 2013;29(12):1535-1552. (Clinical guidelines)
  15. Cooper LT, Baughman KL, Feldman AM, et al. The role of endomyocardial biopsy in the management of cardiovascu lar disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J Am Coll Cardiol. 2007;50(19):1914-1931. (Clinical guidelines)
  16. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC white paper. J Am Coll Cardiol. 2009;53(17):1475-1487. (Clinical guidelines)
  17. Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation. 2006;113(4):593-595. (Review)
  18. Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol. 1987;1(1):3-14. (Pathology study)
  19. Chow LH, Radio SJ, Sears TD, et al. Insensitivity of right ventricular endomyocardial biopsy in the diagnosis of myocarditis. J Am Coll Cardiol. 1989;14(4):915-920. (Autopsy case review; 14 patients)
  20. Hauck AJ, Kearney DL, Edwards WD. Evaluation of postmortem endomyocardial biopsy specimens from 38 patients with lymphocytic myocarditis: implications for role of sampling error. Mayo Clin Proc. 1989;64(10):1235-1245. (Autopsy case review; 38 patients)
  21. Camargo PR, Snitcowsky R, da Luz PL, et al. Favorable effects of immunosuppressive therapy in children with dilated cardiomyopathy and active myocarditis. Pediatr Cardiol. 1995;16(2):61-68. (Retrospective study; 43 patients)
  22. Kleinert S, Weintraub RG, Wilkinson JL, et al. Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression. J Heart Lung Transplant. 1997;16(12):1248-1254. (Prospective study; 29 patients)
  23. McNamara DM, Holubkov R, Starling RC, et al. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation. 2001;103(18):2254-2259. (Randomized controlled trial; 62 patients)
  24. Parrillo JE, Cunnion RE, Epstein SE, et al. A prospective, randomized, controlled trial of prednisone for dilated cardiomyopathy. N Engl J Med. 1989;321(16):1061-1068. (Randomized controlled trial; 102 patients)
  25. Fowler NO, Harbin AD 3rd. Recurrent acute pericarditis: follow- up study of 31 patients. J Am Coll Cardiol. 1986;7(2):300- 305. (Prospective study; 24 patients)
  26. Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005;112(13):2012-2016. (Randomized controlled trial; 120 subjects)
  27. * Raatikka M, Pelkonen PM, Karjalainen J, et al. Recurrent pericarditis in children and adolescents: report of 15 cases. J Am Coll Cardiol. 2003;42(4):759-764. (Retrospective review, 15 patients)
  28. Ratnapalan S, Brown K, Benson L. Children presenting with acute pericarditis to the emergency department. Pediatr Emerg Care. 2011;27(7):581-585. (Retrospective review; 22 patients)
  29. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528. (Randomized controlled trial; 240 patients)
  30. Brucato A, Cimaz R, Balla E. Prevention of recurrences of corticosteroid-dependent idiopathic pericarditis by colchicine in an adolescent patient. Pediatr Cardiol. 2000;21(4):395- 396. (Case report; 1 patient)
  31. Yazigi A, Abou-Charaf LC. Colchicine for recurrent pericarditis in children. Acta Paediatr. 1998;87(5):603-604. (Case series; 3 patients)
  32. Schultz JC, Hilliard AA, Cooper LT, Jr., et al. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc. 2009;84(11):1001-1009. (Review)
  33. Shu-Ling C, Bautista D, Kit CC, et al. Diagnostic evaluation of pediatric myocarditis in the emergency department: a 10- year case series in the Asian population. Pediatr Emerg Care. 2013;29(3):346-351. (Retrospective review; 39 patients)
  34. Canter CE, Simpson KP. Diagnosis and treatment of myocarditis in children in the current era. Circulation. 2014;129(1):115-128. (Review)
  35. Bern C, Montgomery SP. An estimate of the burden of Chagas disease in the United States. Clin Infect Dis. 2009;49(5):e52-e54. (Prevalence study)
  36. Foerster SR, Canter CE, Cinar A, et al. Ventricular remodeling and survival are more favorable for myocarditis than for idiopathic dilated cardiomyopathy in childhood: an outcomes study from the Pediatric Cardiomyopathy Registry. Circ Heart Fail. 2010;3(6):689-697. (Restrospective review; 372 patients)
  37. Schultheiss HP, Kuhl U, Cooper LT. The management of myocarditis. Eur Heart J. 2011;32(21):2616-2625. (Review)
  38. * Durani Y, Giordano K, Goudie BW. Myocarditis and pericarditis in children. Pediatr Clin North Am. 2010;57(6):1281-1303. (Review)
  39. Stiller B. Management of myocarditis in children: the current situation. Adv Exp Med Biol. 2008;609:196-215. (Review)
  40. Amabile N, Fraisse A, Bouvenot J, et al. Outcome of acute fulminant myocarditis in children. Heart. 2006;92(9):1269- 1273. (Retrospective review; 11 patients)
  41. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore). 2003;82(6):385-391. (Prospective study; 204 patients)
  42. Cakir O, Gurkan F, Balci AE, et al. Purulent pericarditis in childhood: ten years of experience. J Pediatr Surg. 2002;37(10):1404-1408. (Retrospective review; 18 patients)
  43. Dupuis C, Gronnier P, Kachaner J, et al. Bacterial pericarditis in infancy and childhood. Am J Cardiol. 1994;74(8):807-809. (Retrospective review; 43 patients)
  44. Humphreys M. Pericardial conditions: signs, symptoms and electrocardiogram changes. Emerg Nurse. 2006;14(1):30-36. (Review)
  45. Saji T, Matsuura H, Hasegawa K, et al. Comparison of the clinical presentation, treatment, and outcome of fulminant and acute myocarditis in children. Circ J. 2012;76(5):1222- 1228. (Survey study; 169 patients)
  46. Teele SA, Allan CK, Laussen PC, et al. Management and outcomes in pediatric patients presenting with acute fulminant myocarditis. J Pediatr. 2011;158(4):638-643. (Retrospective study; 20 patients)
  47. Cooper LT. Giant cell myocarditis in children. Prog Pediatr Cardiol. 2007;24(1):47-49. (Case series; 4 patients)
  48. Kuhn B, Peters J, Marx GR, et al. Etiology, management, and outcome of pediatric pericardial effusions. Pediatr Cardiol. 2008;29(1):90-94. (Retrospective review; 116 patients)
  49. Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2010;126(5):e1361-e1399. (Clinical guidelines)
  50. Fleisher GR, Ludwig S, Bachur RG, et al. Textbook of Pediatric Emergency Medicine, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2010:1791-1793. (Textbook)
  51. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-1230. (Consensus statement)
  52. Tsang TS, El-Najdawi EK, Seward JB, et al. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr. 1998;11(11):1072-1077. (Retrospective review; 73 patients)
  53. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429- 436. (Retrospective study; 1127 patients)
  54. Gibbs CR, Watson RD, Singh SP, et al. Management of pericardial effusion by drainage: a survey of 10 years’ experience in a city centre general hospital serving a multiracial population. Postgrad Med J. 2000;76(902):809-813. (Retrospective review; 46 patients)
  55. Ghelani SJ, Spaeder MC, Pastor W, et al. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes. 2012;5(5):622-627. (Retrospective database review; 514 patients)
  56. Chang YJ, Chao HC, Hsia SH, et al. Myocarditis presenting as gastritis in children. Pediatr Emerg Care. 2006;22(6):439-440. (Case report; 2 patients)
  57. Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis. 2010;52(4):274-288. (Review)
  58. Freedman SB, Haladyn JK, Floh A, et al. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007;120(6):1278-1285. (Retrospective review; 31 patients)
  59. Thompson JL, Burkhart HM, Dearani JA, et al. Pericardiectomy for pericarditis in the pediatric population. Ann Thorac Surg. 2009;88(5):1546-1550. (Retrospective chart review; 27 patients)
  60. Guven H, Bakiler AR, Ulger Z, et al. Evaluation of children with a large pericardial effusion and cardiac tamponade. Acta Cardiol. 2007;62(2):129-133. (Retrospective review; 10 patients)
  61. Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol. 2000;21(4):363-367. (Retrospective review; 20 patients)
  62. Megged O, Argaman Z, Kleid D. Purulent pericarditis in children: is pericardiotomy needed? Pediatr Emerg Care. 2011;27(12):1185-1187. (Case series; 3 patients)
  63. Bohn D, Benson L. Diagnosis and management of pediatric myocarditis. Paediatr Drugs. 2002;4(3):171-181. (Review)
  64. Eisenberg MA, Green-Hopkins I, Alexander ME, et al. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care. 2012;28(11):1173-1178. (Retrospective review; 221 patients)
  65. Soongswang J, Durongpisitkul K, Nana A, et al. Cardiac troponin T: a marker in the diagnosis of acute myocarditis in children. Pediatr Cardiol. 2005;26(1):45-49. (Prospective study; 43 patients)
  66. Levine MC, Klugman D, Teach SJ. Update on myocarditis in children. Curr Opin Pediatr. 2010;22(3):278-283. (Review)
  67. Mahfoud F, Gartner B, Kindermann M, et al. Virus serology in patients with suspected myocarditis: utility or futility? Eur Heart J. 2011;32(7):897-903. (Prospective study; 124 patients)
  68. Elamm C, Fairweather D, Cooper LT. Pathogenesis and diagnosis of myocarditis. Heart. 2012;98(11):835-840. (Review)
  69. Jensen J, Ma LP, Fu ML, et al. Inflammation increases NTproBNP and the NT-proBNP/BNP ratio. Clin Res Cardiol. 2010;99(7):445-452. (Prospective study; 218 patients)
  70. Molina KM, Garcia X, Denfield SW, et al. Parvovirus B19 myocarditis causes significant morbidity and mortality in children. Pediatr Cardiol. 2013;34(2):390-397. (Retrospective review; 19 patients)
  71. Mlczoch E, Darbandi-Mesri F, Luckner D, et al. NT-pro BNP in acute childhood myocarditis. J Pediatr. 2012;160(1):178-179. (Letter to the editor; prospective study; 10 patients)
  72. Koulouri S, Acherman RJ, Wong PC, et al. Utility of B-type natriuretic peptide in differentiating congestive heart failure from lung disease in pediatric patients with respiratory distress. Pediatr Cardiol. 2004;25(4):341-346. (Prospective study; 49 patients)
  73. Skouri HN, Dec GW, Friedrich MG, et al. Noninvasive imaging in myocarditis. J Am Coll Cardiol. 2006;48(10):2085-2093. (Review article)
  74. Levi D, Alejos J. Diagnosis and treatment of pediatric viral myocarditis. Curr Opin Cardiol. 2001;16(2):77-83. (Review)
  75. Martin AB, Webber S, Fricker FJ, et al. Acute myocarditis. Rapid diagnosis by PCR in children. Circulation. 1994;90(1):330-339. (Pathology review; 34 patients)
  76. Ariyarajah V, Spodick DH. Acute pericarditis: diagnostic cues and common electrocardiographic manifestations. Cardiol Rev. 2007;15(1):24-30. (Review)
  77. Bruch C, Schmermund A, Dagres N, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol. 2001;38(1):219-226. (Prospective study; 43 patients)
  78. Kobayashi D, Aggarwal S, Kheiwa A, et al. Myopericarditis in children: elevated troponin I level does not predict outcome. Pediatr Cardiol. 2012;33(7):1040-1045. (Retrospective study; 12 patients)
  79. Bonnefoy E, Godon P, Kirkorian G, et al. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000;21(10):832-836. (Prospective study; 69 patients)
  80. Imazio M, Demichelis B, Cecchi E, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003;42(12):2144-2148. (Prospective study; 118 patients)
  81. Gamaza-Chulian S, Leon-Jimenez J, Recuerda-Nunez M, et al. Cardiac troponin-T in acute pericarditis. J Cardiovasc Med (Hagerstown). 2014;15(1):68-72. (Prospective study; 105 patients)
  82. Doniger SJ. Bedside emergency cardiac ultrasound in children. J Emerg Trauma Shock. 2010;3(3):282-291. (Review)
  83. Mandavia DP, Hoffner RJ, Mahaney K, et al. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001;38(4):377-382. (Prospective study; 103 patients)
  84. Hwang DS, Kim SJ, Shin ES, et al. The N-terminal pro-Btype natriuretic peptide as a predictor of disease progression in patients with pericardial effusion. Int J Cardiol. 2012;157(2):192-196. (Prospective study; 42 patients)
  85. Imazio M, Brucato A, Doria A, et al. Antinuclear antibodies in recurrent idiopathic pericarditis: prevalence and clinical significance. Int J Cardiol. 2009;136(3):289-293. (Prospective study; 145 patients)
  86. Wang ZJ, Reddy GP, Gotway MB, et al. CT and MR imaging of pericardial disease. Radiographics. 2003;23 Spec No:S167- S180. (Review)
  87. * Vashist S, Singh GK. Acute myocarditis in children: current concepts and management. Curr Treat Options Cardiovasc Med. 2009;11(5):383-391. (Review)
  88. * Levi D, Alejos J. An approach to the treatment of pediatric myocarditis. Paediatr Drugs. 2002;4(10):637-647. (Review)
  89. Klugman D, Berger JT, Sable CA, et al. Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol. 2010;31(2):222-228. (Retrospective database review; 216 patients)
  90. Sharma JR, Sathanandam S, Rao SP, et al. Ventricular tachycardia in acute fulminant myocarditis: medical management and follow-up. Pediatr Cardiol. 2008;29(2):416-419. (Case report)
  91. Gagliardi MG, Bevilacqua M, Bassano C, et al. Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart. 2004;90(10):1167-1171. (Prospective study; 114 patients)
  92. Lee KJ, McCrindle BW, Bohn DJ, et al. Clinical outcomes of acute myocarditis in childhood. Heart. 1999;82(2):226-233. (Retrospective review; 36 patients)
  93. Balaji S, Wiles HB, Sens MA, et al. Immunosuppressive treatment for myocarditis and borderline myocarditis in children with ventricular ectopic rhythm. Br Heart J. 1994;72(4):354- 359. (Retrospective review; 69 patients)
  94. Ino T, Okubo M, Akimoto K, et al. Corticosteroid therapy for ventricular tachycardia in children with silent lymphocytic myocarditis. J Pediatr. 1995;126(2):304-308. (Case series; 4 patients)
  95. Aziz KU, Patel N, Sadullah T, et al. Acute viral myocarditis: role of immunosuppression: a prospective randomised study. Cardiol Young. 2010;20(5):509-515. (Randomized controlled trial; 68 patients)
  96. Camargo PR, Okay TS, Yamamoto L, et al. Myocarditis in children and detection of viruses in myocardial tissue: implications for immunosuppressive therapy. Int J Cardiol. 2011;148(2):204-208. (Prospective study; 30 patients)
  97. Chan KY, Iwahara M, Benson LN, et al. Immunosuppressive therapy in the management of acute myocarditis in children: a clinical trial. J Am Coll Cardiol. 1991;17(2):458-460. (Retrospective study; 13 patients)
  98. Mason JW, O’Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995;333(5):269-275. (Randomized controlled trial; 111 patients)
  99. Hia CP, Yip WC, Tai BC, et al. Immunosuppressive therapy in acute myocarditis: an 18 year systematic review. Arch Dis Child. 2004;89(6):580-584. (Systematic review; 9 studies, 236 patients)
  100. Robinson JL, Hartling L, Crumley E, et al. A systematic review of intravenous gamma globulin for therapy of acute myocarditis. BMC Cardiovasc Disord. 2005;5(1):12. (Systematic review; 1 study, 62 patients)
  101. Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation. 1994;89(1):252-257. (Prospective study; 21 patients)
  102. Haque A, Bhatti S, Siddiqui FJ. Intravenous immune globulin for severe acute myocarditis in children. Indian Pediatr. 2009;46(9):810-811. (Retrospective chart review; 25 patients)
  103. English RF, Janosky JE, Ettedgui JA, et al. Outcomes for children with acute myocarditis. Cardiol Young. 2004;14(5):488- 493. (Retrospective chart review; 41 patients)
  104. Kim HJ, Yoo GH, Kil HR. Clinical outcome of acute myocarditis in children according to treatment modalities. Korean J Pediatr. 2010;53(7):745-752. (Retrospective chart review; 33 patients)
  105. Brunetti L, DeSantis ER. Treatment of viral myocarditis caused by coxsackievirus B. Am J Health Syst Pharm. 2008;65(2):132-137. (Review)
  106. Baykurt C, Caglar K, Ceviz N, et al. Successful treatment of Epstein-Barr virus infection associated with myocarditis. Pediatr Int. 1999;41(4):389-391. (Case report)
  107. Rich R, McErlean M. Complete heart block in a child with varicella. Am J Emerg Med. 1993;11(6):602-605. (Case report; 1 patient)
  108. Simpson KE, Canter CE. Acute myocarditis in children. Expert Rev Cardiovasc Ther. 2011;9(6):771-783. (Review)
  109. Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121(7):916-928. (Review)
  110. Schifferdecker B, Spodick DH. Nonsteroidal anti-inflammatory drugs in the treatment of pericarditis. Cardiol Rev. 2003;11(4):211-217. (Review)
  111. Artom G, Koren-Morag N, Spodick DH, et al. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-centre all-case analysis. Eur Heart J. 2005;26(7):723-727. (Retrospective study; 119 patients)
  112. Baszis KW, Singh G, White A, et al. Recurrent cardiac tamponade in a child with newly diagnosed systemic-onset juvenile idiopathic arthritis. J Clin Rheumatol. 2012;18(6):304- 306. (Case report)
  113. Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericarditis: high versus low doses: a nonrandomized observation. Circulation. 2008;118(6):667-671. (Retrospective review; 100 subjects)
  114. Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation. 2005;112(23):3608-3616. (Review)
  115. Del Fresno MR, Peralta JE, Granados MA, et al. Intravenous immunoglobulin therapy for refractory recurrent pericarditis. Pediatrics. 2014;134(5):e1441-e1446. (Case report; 2 patients)
  116. Al Ali AM, Straatman LP, Allard MF, et al. Eosinophilic myocarditis: case series and review of literature. Can J Cardiol. 2006;22(14):1233-1237. (Case series; 3 patients)
  117. Cooper LT Jr, Hare JM, Tazelaar HD, et al. Usefulness of immunosuppression for giant cell myocarditis. Am J Cardiol. 2008;102(11):1535-1539. (Prospective study; 20 patients)
  118. Hidron A, Vogenthaler N, Santos-Preciado JI, et al. Cardiac involvement with parasitic infections. Clin Microbiol Rev. 2010;23(2):324-349. (Review)
  119. Rodriguez-Guerineau L, Posfay-Barbe KM, Monsonis- Cabedo M, et al. Pediatric Chagas disease in Europe: 45 cases from Spain and Switzerland. Pediatr Infect Dis J. 2014;33(5):458-462. (Retrospective review; 45 patients)
  120. Reuter H, Burgess LJ, Doubell AF. Epidemiology of pericardial effusions at a large academic hospital in South Africa. Epidemiol Infect. 2005;133(3):393-399. (Prospective study; 233 patients)
  121. Cruz AT, Starke JR. Clinical manifestations of tuberculosis in children. Paediatr Respir Rev. 2007;8(2):107-117. (Review article)
  122. Hugo-Hamman CT, Scher H, De Moor MM. Tuberculous pericarditis in children: a review of 44 cases. Pediatr Infect Dis J. 1994;13(1):13-18. (Retrospective study; 44 patients)
  123. Chong SL, Bautista D, Ang AS. Diagnosing paediatric myocarditis: what really matters. Emerg Med J. 2015;32(2):138-143. (Case-control study; 78 patients)
  124. Fairweather D, Frisancho-Kiss S, Yusung SA, et al. Interferon- gamma protects against chronic viral myocarditis by reducing mast cell degranulation, fibrosis, and the profibrotic cytokines transforming growth factor-beta 1, interleukin- 1 beta, and interleukin-4 in the heart. Am J Pathol. 2004;165(6):1883-1894. (Animal study)
  125. Heim A, Stille-Siegener M, Kandolf R, et al. Enterovirusinduced myocarditis: hemodynamic deterioration with immunosuppressive therapy and successful application of interferon-alpha. Clin Cardiol. 1994;17(10):563-565. (Case report; 1 patient)
  126. Kishimoto C, Crumpacker CS, Abelmann WH. Prevention of murine coxsackie B3 viral myocarditis and associated lymphoid organ atrophy with recombinant human leucocyte interferon alpha A/D. Cardiovasc Res. 1988;22(10):732-738. (Animal study)
  127. Kishimoto C, Kuroki Y, Hiraoka Y, et al. Cytokine and murine coxsackievirus B3 myocarditis. Interleukin-2 suppressed myocarditis in the acute stage but enhanced the condition in the subsequent stage. Circulation. 1994;89(6):2836-2842. (Animal study)
  128. Kuhl U, Schultheiss HP. Myocarditis in children. Heart Fail Clin. 2010;6(4):483-496. (Review)
  129. Nishio R, Matsumori A, Shioi T, et al. Treatment of experimental viral myocarditis with interleukin-10. Circulation. 1999;100(10):1102-1108. (Animal study)
  130. Daliento L, Calabrese F, Tona F, et al. Successful treatment of enterovirus-induced myocarditis with interferon-alpha. J Heart Lung Transplant. 2003;22(2):214-217. (Case report; 2 patients)
  131. Miric M, Vasiljevic J, Bojic M, et al. Long-term follow up of patients with dilated heart muscle disease treated with human leucocytic interferon alpha or thymic hormones initial results. Heart. 1996;75(6):596-601. (Prospective study; 38 patients)
  132. Kuhl U, Pauschinger M, Schwimmbeck PL, et al. Interferonbeta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation. 2003;107(22):2793-2798. (Prospective study; 22 patients)
  133. Ahdoot J, Galindo A, Alejos JC, et al. Use of OKT3 for acute myocarditis in infants and children. J Heart Lung Transplant. 2000;19(11):1118-1121. (Case series; 5 patients)
  134. Kalimuddin S, Sessions OM, Hou Y, et al. Successful clearance of human parainfluenza virus type 2 viraemia with intravenous ribavirin and immunoglobulin in a patient with acute myocarditis. J Clin Virol. 2013;56(1):37-40. (Case report; 1 patient)
  135. Lenzo JC, Shellam GR, Lawson CM. Ganciclovir and cidofovir treatment of cytomegalovirus-induced myocarditis in mice. Antimicrob Agents Chemother. 2001;45(5):1444-1449. (Animal study)
  136. Leonard EG. Viral myocarditis. Pediatr Infect Dis J. 2004;23(7):665-666. (Review)
  137. Pevear DC, Tull TM, Seipel ME, et al. Activity of pleconaril against enteroviruses. Antimicrob Agents Chemother. 1999;43(9):2109-2115. (Laboratory study)
  138. Finetti M, Insalaco A, Cantarini L, et al. Long-term efficacy of interleukin-1 receptor antagonist (anakinra) in corticosteroid- dependent and colchicine-resistant recurrent pericarditis. J Pediatr. 2014;164(6):1425-1431. (Retrospective study; 15 patients)
  139. Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042-1046. (Prospective study; 254 patients)
  140. Dudzinski DM, Mak GS, Hung JW. Pericardial diseases. Curr Probl Cardiol. 2012;37(3):75-118. (Review)
  141. Imazio M, Cecchi E, Demichelis B, et al. Indicators of poor prognosis of acute pericarditis. Circulation. 2007;115(21):2739- 2744. (Prospective study; 453 patients)
Publication Information

Kelly R. Bergmann, DO; Anupam Kharbanda, MD; Lauren Haveman, MD

Publication Date

July 2, 2015

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.