Lyon – How not to miss a pericarditis in children in the emergency room, while limiting the diagnostics by excess? The advice of Dr Hervé JolyReferential doctor in fetal cardiology (multidisciplinary center for prenatal diagnostic- Hospital of La Croix-Rousse; Hôpital Femme Mère Enfant and Lyon Sud-Hospices Civils de Lyon) during the Congress of the French Pediatric Society [1].
Detect pericardites to avoid complications
Thoracic pain is a frequent reason for consultation in pediatric emergencies, often a source of parental concern related to suspicion of cardiac pathology. However, they are most often benign.
In a review of the literature published in 2024, musculoskeletal causes appear to be the most frequent (38.7 to 86.3 %), ahead of pulmonary etiologies (1.8 to 12.8 %), gastrointestinal (0.3 to 9.3 %), psychogenic (5.1 to 83.6 %) and cardiac (0.3 to 8 %) [2].
Overall, “myocarditis and pericarditis represent approximately 0.5 to 1 % of the etiologies of chest pain in children in children [3] Summarizes Dr. Hervé Joly.
A study from the American database Pediatric Health Information System between 2007 and 2012 (38 hospitals with full data; 11,364 hospitalizations), 4.8 % corresponded to pericarditis/ pericardial or viral pericardial effusion. Few differences between girls and boys, with a mainly male peak in adolescence. The median age was 14.5 years [4].
Why should we detect pericardites? Simply to avoid complications: buffer, myopericarditis, recurrent or chronic pericarditis (more than 3 months), chronic constrictive pericarditis (fibrous thickening). Thus, the challenge is to avoid diagnostic errors without giving in to the excess of explorations. Pericarditis is not a diagnosis to be made by default.
When to think of pericarditis?
The diagnosis is based on a bundle of clinical, electric and ultrasound arguments. “The diagnosis, at least the strong suspicion of acute pericarditis, is based on the presence of at least two of the following four criteria: typical pain, anomalies to auscultation, modifications to ECG, evocative ultrasound, lists the cardiopediatrician. Complementary elements include inflammatory biomarkers and imaging.
The European Cardiology Society (ESC, 2015) [5]listed the essential examinations in the event of suspicion of acute pericarditis. ECG is recommended in all patients as well as transthoracic echocardiography, pulmonary radiography, evaluation of inflammation markers (CRP) and myocardial lesions (creatine kinase, troponin). »»
The clinical context in the typical and in particular viral phases associates chest pain, pseudo-grippal syndrome in the previous days, infectious storytelling, moderate fever, myalgia and fairly clear asthenia (in clear, it is grumpy).
Precisely, the clinic – the clinical entry door of pericarditis – classic combines strong retrosternal chest pain or prolonged left pre -cordial at rest as well as for effort (nothing to do with the intercostal pinch frequently seen in the emergency room, or the chest pain of a suspicion of coronary anomaly which manifests itself). This is increased in decubitus and deep inspiration, calmed into anteflection, and sometimes a dyspnea relieved in a seated position leaning forward, dry cough, dysphonia and hiccups.
Auscultation highlights a pathognomonic, early, systolo-diastolic, rare, variable, variable, positions (do not hesitate to examine the child in a sitting position, lying down), persisting in apnea, maximum at the left stern (noise evoking a new leather or steps in fresh snow); This sign confirms the diagnosis but remains inconsistent and fleeting. We can also note a pleural effusion and tachycardia.
One ECG can hide another
The initial electrocardiogram (ECG) can be normal. This is why, “you have to know how to repeat it in time, even in the day,” insists Dr. Joly. The ECG can reveal atrial anomalies, in particular an underdevelopment of the PQ segment, an early, transient and inconsistent sign, descending and diffuse in precordial derivations (absent in AVR where we observe a slight above-mentioning). This phenomenon corresponds to a current of atrial lesion.
The ECG shows diffuse, non-systematized ventricular anomalies, without mirror image, which evolve in four stages: aforementioned ST segment upwards, positive T waves except AVR and V1 (J1, Stage 1); Stade T waves Stade (J1-J2, stadium 2); negativation of T waves (J7; Stade 3); Normalization of the ECG (stadium 4).
Early repolarization or pericarditis?
Differentiating early repolarization and pericarditis can be difficult. With the difference that early repolarization is not accompanied by pain or pericardial clinical signs, and the underdevelopment of the PQ segment is absent. It is characterized by the presence of a positive J wave or a misunderstanding at the end of QRS, a generally pointed wave, observable on two contiguous derivations.
Among the other signs, the ECG shows a sinus tachycardia and microvoltage in the event of abundant pericardial effusion, with QRS complexes whose amplitude is less than 5 mm in peripheral derivations and 10 mm in precordial derivations.
The pulmonary x -ray is most often normal, but can reveal cardiomegaly with a carafe -shaped heart in the event of abundant pericardial effusion. “If this imagery is important, it is because it helps the etiological diagnosis by identifying an associated pulmonary pathology or pleural effusion,” says the specialist.
As for biology, this must be limited in the absence of clinical orientation, signs of severity or recurrence, and include inflammatory markers (blood formula, C-reactive protein), markers of myocardial damage (troponins) as well as the blood ionogram, urea and creatinine (to remove renal insufficiency in the case of the prescription of NSAIDs).
Echocardiography is often normal in the event of “dry” pericarditis; It makes it possible to detect a pericardial effusion, classified as a minimal (<10 mm), moderate (10-20 mm) or abundant (> 20 mm) in diastole. The buffer manifests itself in much more frank clinical signs than a simple pericarditis, with a dyspnea of progressive aggravation, orthopneous, tachycardia, jugular turgency, hypotension and rapid evolution towards a state of shock.
Always thanks to echocardiography, it is possible to assess the contractile function of the left ventricle and detect a pericardial/mediastinal mass.
Finally, the chest scanner and MRI, used in second intention, are used for etiological diagnosis. In the event of a buffer, the CT makes it possible to ensure that pericarditis is not linked to a mediastinal tumor, before making drainage.
Hospitalize or not?
Hospitalization is essential in the presence of at least one of the four major predictors: fever greater than 38 ° C, prolonged symptoms for several days or weeks, abundant pericardial effusion (> 20 mm) or buffer, resistance to anti-inflammatory treatment (aspirin or NSAIDs) after 7 days, or myocardial damage.
The most frequent and generally benign etiology includes viral infections, including enterovirus (Coxsackie, Echovirus), as well as Epstein-Barr virus, cytomegalovirus, HHV6 virus, adenovirus, parvovirus B19, influenza, dengue and chikungunya. “In this regard,” Slides Hervé Joly, the serologies are generally useless in typical forms without a sign of gravity. »»
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