Myocarditis and pericarditis — structured clinical encounter

Structured encounter testing the approach to a nine-year-old boy who presents a week after a viral illness with central chest pain, breathlessness and palpitations, a gallop rhythm, a markedly raised troponin, widespread electrocardiographic changes and ventricular dysfunction: the diagnostic triad of troponin, electrocardiogram and echocardiogram, the cardiac magnetic resonance confirmation, the supportive-first management with activity restriction, the selective-immunotherapy reasoning, the fulminant escalation to mechanical circulatory support, and the conversation with the family about the recovery outlook and the return-to-sport plan.

structured clinical encounter

Prompt

A nine-year-old previously well boy presents to the emergency department one week after a febrile respiratory illness. He reports central chest pain, breathlessness on walking and palpitations. On examination he is tachycardic at 130 beats per minute with a gallop rhythm, a respiratory rate of 40, cool peripheries and a capillary refill of four seconds. The high-sensitivity troponin is markedly raised. The electrocardiogram shows widespread ST-segment and T-wave changes with occasional ventricular ectopic beats. The echocardiogram shows a moderately impaired left ventricular ejection fraction with global hypokinesis and a trivial pericardial effusion. A diagnosis of acute myocarditis is made. You are the paediatric registrar working through the case.

Encounter structure

The candidate works through the case in five phases: [1]

Recognition (5 minutes): Identify acute myocarditis from the viral prodrome, the chest pain and breathlessness, the gallop rhythm and the markedly raised troponin; anchor the diagnosis on the triad of troponin, electrocardiogram and echocardiogram; distinguish it from anomalous coronary disease, pulmonary embolism and sepsis with myocardial depression. [3]
Immediate management (5 minutes): Admit to a monitored bed in a centre with paediatric cardiac and intensive-care support; restrict activity absolutely; treat any arrhythmia; support the circulation cautiously with inotropes guided by perfusion and lactate; arrange cardiac magnetic resonance confirmation once the child is stable. [8]
Investigation and risk stratification (5 minutes): Confirm the Lake Louise magnetic resonance criteria; discuss the selective role of endomyocardial biopsy; decide against routine intravenous immunoglobulin and corticosteroids on the basis of the Cochrane evidence, while holding them in reserve for autoimmune or giant cell disease. [4] [6]
The fulminant deterioration and family conversation (5 minutes): Recognise the deterioration to cardiogenic shock with a rising lactate and sustained ventricular tachycardia; escalate to early venoarterial extracorporeal membrane oxygenation or a ventricular assist device; explain to the family that fulminant myocarditis, despite its severity, often recovers near-normal function once the child is supported through the storm. [8]
Follow-up planning (5 minutes): Outline the three-to-six-month activity restriction with no competitive sport, the serial echocardiography and troponin until normalisation, the surveillance for evolution to dilated cardiomyopathy, and the structured return to activity. [1]

References

[1]Law YM; Lal AK; Chen S; et al Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association Circulation, 2021.PMID 34229446
[2]Tunuguntla H; Jeewa A; Denfield SW Acute Myocarditis and Pericarditis in Children Pediatr Rev, 2019.PMID 30600275
[3]Ammirati E; Moslehi JJ; et al Diagnosis and Treatment of Acute Myocarditis: A Review JAMA, 2023.PMID 37014337
[4]Ferreira VM; Schulz-Menger J; Holmvang G; et al Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations J Am Coll Cardiol, 2018.PMID 30545455
[5]Friedrich MG; Sechtem U; Schulz-Menger J; et al Cardiovascular magnetic resonance in myocarditis: A JACC White Paper J Am Coll Cardiol, 2009.PMID 19389557
[6]Robinson J; Hartling L; Crumley E; et al Intravenous immunoglobulin for presumed viral myocarditis in children and adults Cochrane Database Syst Rev, 2020.PMID 32835416
[7]Li Y; Yu Y; Dong R; et al Corticosteroids and Intravenous Immunoglobulin in Pediatric Myocarditis: A Meta-Analysis Front Pediatr, 2019.PMID 31475124
[8]Kwon HW When should mechanical circulatory support be considered in pediatric patients with acute fulminant myocarditis? Clin Exp Pediatr, 2021.PMID 32972050
[9]McMurray JC; May JW; Cunningham A; et al Multisystem Inflammatory Syndrome in Children (MIS-C), a Post-viral Myocarditis and Systemic Vasculitis-A Critical Review of Its Pathogenesis and Treatment Front Pediatr, 2020.PMID 33425823
[10]Wu EY; Campbell MJ; et al Cardiac Manifestations of Multisystem Inflammatory Syndrome in Children (MIS-C) Following COVID-19 Curr Cardiol Rep, 2021.PMID 34599465
[11]Bozkurt B; Kamat I; Hotez PJ Myocarditis With COVID-19 mRNA Vaccines Circulation, 2021.PMID 34281357
[12]Shahid R; Jin J; Cooper JN; et al Pediatric Pericarditis: Update Curr Cardiol Rep, 2023.PMID 36749541
[13]Imazio M; Gaita F; LeWinter M Evaluation and Treatment of Pericarditis: A Systematic Review JAMA, 2015.PMID 26461998
[14]Alsabri M; Elsayed SM; Alsahlly A; et al Efficacy and Safety of Colchicine in Pediatric Pericarditis: A Systematic Review and Future Directions Pediatr Cardiol, 2025.PMID 39080042
[15]Perez-Casares A; Cesar S; Brunet-Garcia L; et al Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade Front Pediatr, 2017.PMID 28484689

Myocarditis and pericarditis — structured clinical encounter

structured clinical encounter

References

[1]Law YM; Lal AK; Chen S; et al Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association Circulation, 2021.PMID 34229446

[2]Tunuguntla H; Jeewa A; Denfield SW Acute Myocarditis and Pericarditis in Children Pediatr Rev, 2019.PMID 30600275

[3]Ammirati E; Moslehi JJ; et al Diagnosis and Treatment of Acute Myocarditis: A Review JAMA, 2023.PMID 37014337

[4]Ferreira VM; Schulz-Menger J; Holmvang G; et al Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations J Am Coll Cardiol, 2018.PMID 30545455

[5]Friedrich MG; Sechtem U; Schulz-Menger J; et al Cardiovascular magnetic resonance in myocarditis: A JACC White Paper J Am Coll Cardiol, 2009.PMID 19389557

[6]Robinson J; Hartling L; Crumley E; et al Intravenous immunoglobulin for presumed viral myocarditis in children and adults Cochrane Database Syst Rev, 2020.PMID 32835416

[7]Li Y; Yu Y; Dong R; et al Corticosteroids and Intravenous Immunoglobulin in Pediatric Myocarditis: A Meta-Analysis Front Pediatr, 2019.PMID 31475124

[8]Kwon HW When should mechanical circulatory support be considered in pediatric patients with acute fulminant myocarditis? Clin Exp Pediatr, 2021.PMID 32972050

[9]McMurray JC; May JW; Cunningham A; et al Multisystem Inflammatory Syndrome in Children (MIS-C), a Post-viral Myocarditis and Systemic Vasculitis-A Critical Review of Its Pathogenesis and Treatment Front Pediatr, 2020.PMID 33425823

[10]Wu EY; Campbell MJ; et al Cardiac Manifestations of Multisystem Inflammatory Syndrome in Children (MIS-C) Following COVID-19 Curr Cardiol Rep, 2021.PMID 34599465

[11]Bozkurt B; Kamat I; Hotez PJ Myocarditis With COVID-19 mRNA Vaccines Circulation, 2021.PMID 34281357

[12]Shahid R; Jin J; Cooper JN; et al Pediatric Pericarditis: Update Curr Cardiol Rep, 2023.PMID 36749541

[13]Imazio M; Gaita F; LeWinter M Evaluation and Treatment of Pericarditis: A Systematic Review JAMA, 2015.PMID 26461998

[14]Alsabri M; Elsayed SM; Alsahlly A; et al Efficacy and Safety of Colchicine in Pediatric Pericarditis: A Systematic Review and Future Directions Pediatr Cardiol, 2025.PMID 39080042

[15]Perez-Casares A; Cesar S; Brunet-Garcia L; et al Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade Front Pediatr, 2017.PMID 28484689