What Is the Classic Clinical Presentation of Pericarditis?

Patient Presentation
A 10-year-old male was brought by ambulance from his local doctor’s for worsening chest pain and suspected pericarditis or myocarditis. He had a 3 day history of mild cough, rhinorrhea and fever. On the day of admission his fever spiked to 103.8°F and he started to complain of left sided chest pain that was worsening. His mother said the cough was getting slightly worse and he seemed more tired but more agitated at the same time. He refused to lie down and asked to go to the doctor. The local physician heard a pericardial rub and referred him to the emergency department. The past medical history was normal. The family history had no significant cardiac history.

The pertinent physical exam showed a wide-eyed school ager, who was sitting up on the gurney. His blood pressure was 124/78, pulse of 118, respiratory rate of 32 with an oxygen saturation of 98%. He endorsed chest pain in the precordial area without radiation. Capillary refill was brisk. His HEENT showed mild pharyngitis and rhinorrhea. His cardiac examination showed no obvious murmur with a normal S1 and S2. He had a pericardial friction rub but no jugulovenous distension or hepatomegaly. Peripheral pulses were brisk.

The diagnosis of presumed pericarditis was made. The radiologic evaluation of a chest radiograph showed no cardiac silhouette enlargement. His electrocardiogram had mild ST segment elevation changes. His cardiac enzymes were normal. A cardiologist was consulted who also performed an echocardiogram which showed mild pericardial effusion and normal cardiac structures, movement and ejection fractions. She agreed with the diagnosis and the patient was admitted. He was monitored closely and his fever curve slowly decreased over the next 4 days. He slowly also started to feel better and was discharged on day 6. The laboratory evaluation was positive for adenovirus.

Discussion
The pericardium is a bi-layered membrane that envelops the heart and provides a barrier to prevent disease and also decreases friction as the heart moves. Pericarditis is the inflammation of pericardium. The incidence is underreported as asymptomatic or mild disease may go unrecognized. From hospitalized patient data, 0.2-5% of patients with various cardiac disease had pericarditis. An incidence rate for hospitalizations of 3.32 per 100,000 person years has been cited. Percarditis occurs more often in adolescent males.

Treatment of the underlying cause or suspected cause is important, along with close monitoring for worsening effusion and/or other worsening physical examination signs. Nonsteroidal anti-inflammatory medications are helpful to decrease pain and to reduce inflammation. Colchicine is used for recurrent pericarditis which can occur in up to 10% of patients. Steroid therapy is used usually when there is an underlying systemic inflammatory disease. Other options include azothioprine, anakinra or intravenous immunoglobulins.

In the developed world viral etiology or presumed viral etiology are 80-90% of cases. Worldwide tuberculosis is the most common cause and is associated with a high incidence of co-infection with human immunodeficiency virus. Viruses, bacteria, fungi, protozoa, autoimmune, neoplastic, metabolic and drugs can cause pericarditis. In the developed world the causes of pericarditis are similar to myocarditis which can be reviewed here. Prognosis is good with resolution for most patients especially with viral etiology. Bacterial pericarditis has a worse prognosis.

Learning Point
Typically pericarditis presents with pleuritic chest pain that is improved with sitting up and leaning forward and high fever. The chest pain is worsened with cough, movement and even just breathing. Patients with pericarditis often will resist lying down. On auscultation of the heart, classically a frictional rub is heard throughout the cardiac cycle. Large effusions may not have a rub and often have distant heart sounds. Signs of pericardial tamponade include jugular venous distension, hepatomegaly and poor peripheral perfusion.

A chest radiograph is usually obtained as it is often available and typically shows an enlarged cardiac silhouette and potentially increased pulmonary vascular markings. The cardiac silhouette can be normal though also. Electrocardiograms are also often available and classically show ST-segment elevation and low voltage QRS complexes. Echocardiograms, if available, can show the actual effusion and its size, and also help determine if there is associated myocarditis as well (20-30% of patients have both).

“Acute pericarditis is diagnosed based up on the presence of two of the following: chest pain that is consistent with pericarditis, pericardial friction rub, suggestive changes on [electrocardiogram], and new or worsening pericardial effusion.”

Questions for Further Discussion
1. How is myocarditis different than pericarditis? A review can be found here
2. How are pericardial and pleural effusions similar and different?
3. What is in the differential diagnosis of chest pain? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Pericardial Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763

Leong K, Kane JM, Joy BF. Acquired Cardiac Disease in the Pediatric Intensive Care Unit. Pediatr Ann. 2018;47(7):e280-e285. doi:10.3928/19382359-20180620-01

Tunuguntla H, Jeewa A, Denfield SW. Acute Myocarditis and Pericarditis in Children. Pediatr Rev. 2019;40(1):14-25. doi:10.1542/pir.2018-0044

Areias JC. Pericarditis: Characteristics of a pediatric population. Rev Port Cardiol. 2019;38(2):103-104. doi:10.1016/j.repc.2019.02.003

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Indications for Wisdom Teeth Removal?

Patient Presentation
A 14-year-old female came to clinic for her health supervision visit. Her mother was concerned because the patient was scheduled to have her wisdom teeth out as part of planned orthodontic treatment. “In my home country we don’t take teeth out very much. Only if they are rotten. We also have alot more rotten teeth too,” the mother stated. The past medical and family history were non-contributory including no problems with anesthesia.

The pertinent physical exam showed a healthy female with normal vital signs with her height and weight in the 25-50%. She had an obvious malalignment of multiple teeth. The rest of her examination was normal. The diagnosis of a healthy female was made. The pediatrician recommended that the mother discuss the procedure with their dentist, orthodontist and dental surgeon so she would better understand the reasons they were recommending the dental extraction.

Discussion
Third molars (M3) are often referred to as wisdom teeth. They begin calcification at 7-9 years and usually erupt between 17-26 years. They usually erupt behind the second molar into what may be limited space. M3 can also fail to erupt. Impacted M3 occur because of abnormal position, obstruction, or lack of space.

There are 4 potential groups to consider for M3 management:

  • Group 1 – symptomatic with clinical disease
    • Epidemiology: common
    • Clinical presentations: edema, pain, trismus
    • Disease: caries, pericoronitis and infection are common
    • Treatment: treatment of disease is important but extraction is recommended because patient is symptomatic and has clinical disease
  • Group 2 – symptomatic without clinical disease
    • Epidemiology: doesn’t occur frequently and hard to discern
    • Clinical presentations: vague pain
    • Treatment: Discussion with patient regarding risks and benefits of symptoms that may or may not be attributable to M3
  • Group 3 – asymptomatic with clinical disease
    • Clinical presentations: none
    • Disease: caries, periodonitis, cysts or tumors
    • Treatment: treatment of disease is important but extraction is often recommended because patient has clinical disease

  • Group 4 – asymptomatic without clinical disease
    • Epidemiology: often occurs depending on age
    • Clinical presentations: none
    • Treatment: Controversial, “Available evidence is insufficient to show whether or not asymptomatic disease-free impacted wisdom teeth should be removed.”

Learning Point

Some problems associated with M3 and potential indications for removal include:

  • Gum disease with edema or ulceration
  • Bone disease including cysts or tumors, fractures
  • Damage to adjacent structures – e.g. roots of adjacent teeth
  • Infection – localized or adjacent
  • Spacing problems for arch and dental structures – orthodontic or orthognathic surgical indications
  • Non-functional, non-hygenic tooth
  • Interference with removable prosthetics (e.g. dentures)

Potential problems with M3 surgical removal include:

  • Bleeding
  • Cost
  • Fracture
  • Osteitis or other infections
  • Nerve injury
  • Periodontal defects

M3 that are asymptomatic without clinical disease often over time are removed because they do develop disease. About 30% of these asymptomatic, unerupted M3 will move over time and cause problems. Thirty to sixty percent of patients who initially retained their M3 have them extracted between 4-12 years later. There is also little evidence for or against active surveillance for potential future disease in asymptomatic non-diseased M3. Complications of surgical removal once disease begins includes more difficulty in treating the disease, spread of disease to adjacent dental or facial structures, and increased risks of complications with surgical removal of M3s.

The first and second molar also have indications for their removal which can be reviewed in the to Learn More section below.

Questions for Further Discussion
1. When should infants and young children have their first dental visit?
2. When should children receive fluoride treatments for their teeth or sealants?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tooth Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Hatami A, Dreyer C. The extraction of first, second or third permanent molar teeth and its effect on the dentofacial complex. Aust Dent J. August 2019. doi:10.1111/adj.12716

Steed MB. The indications for third-molar extractions. J Am Dent Assoc 1939. 2014;145(6):570-573. doi:10.14219/jada.2014.18

Dodson TB, Susarla SM. Impacted wisdom teeth. BMJ Clin Evid. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4148832/. Accessed October 7, 2019.

Ghaeminia H, Perry J, Nienhuijs MEL, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. Cochrane Database Syst Rev. 2016;(8):CD003879. doi:10.1002/14651858.CD003879.pub4

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Holiday Break

PediatricEducation.org is taking an end of the year break. short break. The next case will be published on January 6,2020. If you are inclined you can review “Why Is it Called Christmas Disease?”

Or take a look at the new Curriculum Map for pediatric residents based on the American Board of Pediatrics content outline.

We appreciate your patronage,
Donna D’Alessandro and Michael D’Alessandro, curators.

What Are Some Potential Adverse Effects of Blood Donation?

Patient Presentation
A 17-year-old female came to clinic for her health maintenance examination. She was doing well and was participating in cross-country and track. She had no concerns. The pertinent physical exam revealed a healthy female with normal vital signs. Her height and weight were 50%. The diagnosis of a healthy female was made.

“I noticed that you said you had fainted on your sports physical questionnaire. What happened?” inquired the pediatrician. “Well I gave blood in the spring for the first time and passed out when I first stood up. It was really embarrassing. I was okay after that though,” she replied. “It’s never happened before or after?,” he asked. “No, never before or since. I was okay. I just sort of slumped over and fell back on the bed but never really lost consciousness. I just sat there for a bit longer and had some juice. It was really embargassing,” she stated. “And you’ve never had any other problems like your heart racing or beating funny or any other problems when exercising?” he asked. “No, no other problems. They also told me that I can give blood again which I’m going to do. I’m just going to drink more and make sure I stand up more slowly next time,” she commented.

Discussion
Just under 40% of people are eligible to be a blood donor. Up to 6.5% of a population are actual donors. “Blood donors are healthy volunteers who give either whole blood or blood components by apheresis including platelets, plasma, red blood cells, peripheral blood stem cells and leucocytes or a combination of blood components. They represent a large, healthy population exposing themselves voluntarily for altruistic, sometimes financial motives to potential complications and risks.” Blood banking systems world-wide are responsible for caring for individual donors health as well as maintaining a robust blood supply for the general population. The safest blood donors are voluntary, non-remunerated blood donors from low-risk populations,” per the World Health Organization. Young donors < 18 year old make up more than 10% of the donations in the U.S, and therefore are a very important resource for blood.

The common blood types are O+ (39%), A+ (30%), O- and B+ (9%), A- (6%), AB+ (4%) and AB- (2%). “In an emergency, anyone can receive type O red blood cells. Therefore, people with type O blood are known as “universal donors.” In addition, individuals of all types can receive type AB plasma because it does not contain anti-A or anti-B.”

Eligibility criteria for blood donation by the American Red Cross can be found here. Topics related to blood safety by the World Health Organization can be found here.

Learning Point
Adverse events directly related to blood donation is ~1%. Adverse events are more likely in first time donors, younger donors and women. Young age group is at higher risk for adverse events, up to 12% and there is a higher rate in 16-17 year olds compared to 18-19 year olds.


Common and uncommon adverse effects include:

  • Vasovagal reactions – 1.4 – 7% for moderate reaction, 0.1 – 0.5% for severe reaction,
    • Vasovagal effects include apprehension, diaphoresis, dizziness, weakness, pallor, hypotension and bradycardia
    • Hospitalizations are rare and usually due to fall-related injuries
    • Vasovagal events are more likely to occur in first time donors, younger donors, low weight, non-black race, pre-donation rapid pulse or lower blood pressure
  • Venipuncture problems
    • Hematoma – 9 – 23%
    • Nerve injury – 0.016 – 0.9%
    • Arterial puncture – 0.003% – 0.011%
  • Iron deficiency anemia
    • Common in regular frequency donors – 48 – 66%
    • Restless legs syndrome (RLS) due to iron deficiency – 14 – 25%
  • Other
    • Allergic reaction to tape, disinfecting agent, nickle, etc.
    • False positive screening tests – a list of screening tests can be found here
    • Fatalities – a few case reports with underlying problems such as myocardial infarction

Adverse event prevention includes pre-donation education about what to expect, increasing fluid intake before phlebotomy, exercising large muscle groups during phlebotomy and afterwards to increase circulation, support during phlebotomy (e.g. verbal distraction or engagement), and calm environment to provide and maintain psychological support for the donor. For iron deficiency anemia, iron supplementation and/or restriction of donation frequency is usually used.

Questions for Further Discussion
1. How is blood volume estimated for a healthy person?
2. What blood products are made from whole blood?
3. What are the problems with blood that cannot make it easily synthesized?
4. What are indications for bone marrow donation, and what are the eligibility criteria?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Blood Transfusion and Donation

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Amrein K, Valentin A, Lanzer G, Drexler C. Adverse events and safety issues in blood donation–a comprehensive review. Blood Rev. 2012;26(1):33-42. doi:10.1016/j.blre.2011.09.003

Eder AF. Improving safety for young blood donors. Transfus Med Rev. 2012;26(1):14-26. doi:10.1016/j.tmrv.2011.07.008

Wiersum-Osselton J, Romeijn B, van den Brekel E, et al. Can we prevent vasovagal reactions in young inexperienced whole blood donors? A placebo controlled study comparing effects of a 330 vs 500 mL water drink prior to donation. Transfusion (Paris). 2019;59(2):555-565. doi:10.1111/trf.15065

World Health Organzation. Voluntary non-remunerated blood donation. WHO. http://www.who.int/bloodsafety/voluntary_donation/en/. Accessed October 3, 2019.

Blood FAQ. AABB.org. http://www.aabb.org/tm/Pages/bloodfaq.aspx. Accessed October 4, 2019.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa