Download Chest Pain in a 17-Year-Old Girl with Chickenpox

Case Challenge
Chest Pain in a 17-Year-Old Girl
with Chickenpox
Abdenasser Drighil, MD; Ayoub El hammiri, MD; and Fatima Belmourida, MD
A
17-year-old girl presented with a
7-day history of pruritic vesicular rash (Figure 1), chest pain,
and general malaise. In the preceding
2 weeks, her 9-year-old sister had contracted a similar rash that was diagnosed
clinically as “chicken pox” (ie, varicellazoster virus [VZV]). Initial treatment included salicylates and topical treatment.
The patient had experienced no major illness prior to these symptoms. There was
no relevant family history of heart disease.
On admission, the physical examination revealed a typical VZV rash. The
cardiac examination was benign except
for a heart rate of 105 beats/minute. The
patient was afebrile, and her blood pressure was 125/60 mm Hg. The lungs
were clear to auscultation, the first and
second heart sounds were normal, there
were no murmurs, clicks, or rubs, and
the liver was not enlarged. An electrocardiogram confirmed sinus tachycardia
(105 beats/minute) and revealed an upwardly concave ST-segment elevation
in leads V3-V6, II, and aVF (Figure 2);
these abnormalities returned to normal 5
days later.
Laboratory investigation showed an
elevated creatine kinase (CK) of 194 U/L
with a CK myocardial band concentration of 39 U/L. Other elevations included
troponin I at 2.99 mcg/L, lactate dehydrogenase at 359 U/L, and C-reactive
protein at 8 mg/L. Her white cell count
was 10,110/mm3 with 47% neutrophils,
43% lymphocytes, and 6.2% monocytes.
Fibrinogen was 5.5 g/L, and creatinine,
blood urea nitrogen, and hepatic transaminase levels were all normal. An enzyme-linked immunosorbent assay was
positive for VZV with elevated immunoglobulin M and immunoglobulin G (5.3
and 1.9 mUI/mL, respectively). Serologic
studies for hepatitis B and C and HIV
were negative.
Two-dimensional echocardiography
revealed left ventricular (LV) apical, inferolateral, and inferoseptal hypokinesis, but with a normal global LV ejection
fraction of 58%. There was trivial mitral
regurgitation and a small pericardial effusion.
Figure 1. Vesicular rash on the nose and cheek area.
Abdenasser Drighil, MD, is a Professor. Ayoub
El hammiri, MD, is a Resident. Fatima Belmourida,
MD, is a Resident. All authors are affiliated with
the Department of Cardiology at Ibn Rochd University Hospital.
Address
hammiri,
correspondence
MD,
Department
to
Ayoub
of
Cardiology,
El
Ibn Rochd University Hospital, 1er Quartier
des hôpitaux, Casablanca, Morocco; email:
[email protected].
Disclosure: The authors have no relevant financial relationships to disclose.
doi: 10.3928/00904481-20150910-05
Figure 2. Electrocardiogram showing sinus tachycardia and upwardly concave ST-segment elevation in
leads V3, V4, V5, V6, DII, and aVF.
For diagnosis, see page 364
Editor’s note: Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome
via email at [email protected].
continued on page 364
PEDIATRIC ANNALS • Vol. 44, No. 9, 2015
359
Case Challenge
continued from page 359
Diagnosis:
Varicella Myocarditis
Delayed reperfusion imaging by
magnetic resonance imaging with gadolinium injection showed inferoseptal LV
hypokinesies with minimal pericardial
effusion (Figure 3), consistent with a diagnosis of varicella myocarditis.
The patient was treated with acyclovir (10 mg/kg/day intravenously) for the
first 48 hours, then acyclovir (30 mg/kg
per day orally) and a nonsteroidal antiinflammatory agent (diclofenac 50 mg
3 times daily) for 8 days, and then atenolol
(50 mg daily) and ramipril (2.5 mg daily)
after the diagnosis of varicella myocarditis. CK returned to normal by the fifth
day. Arrhythmias were not observed at
any time. During 3 months of followup, LV systolic function as assessed by
echocardiography increased to 65%.
DISCUSSION
VZV or common chickenpox is a
highly contagious disease that usually
runs a benign course, but in the neonatal period and in immunocompromised
patients, rare and serious complications
A
may be encountered,1 including the development of cardiomyopathy with subsequent heart failure.
In adults, VZV myocarditis with associated arrhythmias is less well documented. VZV myocarditis in adults as
well as in children may be associated
with severe complications, including
progressive heart failure as well as malignant arrhythmias and sudden death.2
Lorber et al.3 found that the typical
time course for discovery of cardiac involvement was 2 weeks or longer after
the onset of a typical skin rash.
Limited information is available regarding the subclinical myocardial insult in the course of VZV infection. It
can only be assumed that were it looked
for, more cases of covert mild cardiac involvement might be found compared to
those with frank overt signs and symptoms of cardiac decompensation.4 When
detected, cardiac involvement commonly includes only nonspecific T wave
changes on the electrocardiogram.2 This
suggests the possibility that subclinical
myocarditis may be present in most cases of acute VZV infection and that it can
be diagnosed in a more comprehensive
cardiac diagnostic examination after the
appearance of the typical rash.
B
Figure 3. Cardiac magnetic resonance imaging. (A) Four-chambers slice highlighting uptake contrast at
lateral and posterior wall after injection of gadolinium (arrow). (B) Cardiac short-axis cut highlighting
uptake contrast at lateral wall after injection of gadolinium (arrow).
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The treatment of acute VZV myocarditis is largely supportive, but because of the rarity of this disease, there
are no generally accepted therapeutic
guidelines. This includes the use of
acyclovir, an inhibitor of herpesvirus
DNA replication. Because of the rarity
of VZV myocarditis, there are no data
to support its effectiveness. Acyclovir
is the drug most commonly used in the
treatment of immunocompetent adults
with VZV. One small prospective and
several retrospective reports suggest
clinical benefits,5,6 and most experts
recommend its use in adults with VZV
complications.7 Given its minimal toxicity, acyclovir seems warranted in
the setting of acute symptomatic VZV
myocarditis.
Acyclovir is useful against VZV for
preventing dissemination in immunocompromised children, and in shortening the duration of fever and skin manifestations when given orally within 24
hours of the development of the rash.8
We speculate that acyclovir may be
beneficial in VZV myocarditis if presentation occurs during the stage of viral replication within the myocardium.
This is more likely early in the course
of the illness, when new skin lesions
are still appearing. Steroids have been
used experimentally in patients with
myocarditis;9 However, there have been
no controlled studies supporting their
effectiveness in infectious myocarditis
associated with VZV. Similarly, immunosuppression has not been shown to
prevent long-term cardiac morbidity,
and its use remains controversial.
CONCLUSION
VZV myocarditis is infrequently diagnosed. We suspect that clinical manifestations would be found more often
if a comprehensive diagnostic investigation were undertaken after the appearance of the characteristic rash, and
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Case Challenge
especially if the presentation included
complaints of chest pain. Primary care
and emergency department medical
providers should be aware of the potential for cardiac involvement in patients
who present with common VZV infection.
REFERENCES
1. Feldman S, Hughes WT, Daniel CB. Varicella in children with cancer: seventy-seven
cases. Pediatrics. 1975;56:388-397.
2. Fiddler GI, Campbell RW, Pottage A, God-
PEDIATRIC ANNALS • Vol. 44, No. 9, 2015
man MJ. Varicella myocarditis presenting
with unusual ventricular arrhythmias. Br
Heart J. 1977;39:1150-1153.
3. Lorber A, Zonk Z, Maisuls E, Dembo L,
Palant A, Iancu TC. The scale of myocardial
involvement in varicella myocarditis. Int J
Cardiol. 1988;20:257-262.
4. Kajalainen J, Viitasalo M, Kalq VR, Heikkila
J. 24-hour electrocardiographic recordings
in mild acute infectious myocarditis. Ann
Clin Res. 1984;16:34-39.
5. Al-Nakib W, Al-Kandari S, El-Khalik D, ElShirbiny AM. A randomised controlled study
of intravenous acyclovir (Zovirax) against
placebo in adults with chicken pox. Infect
Dis. 1983;6:49-56.
6. Feder HM Jr. Treatment of adult chickenpox with oral acyclovir. Arch Intern Med.
1990;150:2061-2065.
7. Straus SE, Ostrove JM, Inchauspe G, et al.
Varicella-zoster virus infections: biology,
natural history, treatment, and prevention.
Ann Intern Med. 1988;108:221-237.
8. Balfour HH Jr, Kelly JM, Suarez CS. Acyclovir treatment of varicella in otherwise
healthy children. J Pediatr. 1990;116:633839.
9. Chan KY, Iwahara M, Benson LN, Wilson
GJ, Freedom RM. Immunosuppressive therapy in the management of acute myocarditis
in children: a clinical trial. J Am Coll Cardiol. 1991;17:458-460.
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