A 11-year-old female child, who was apparently well 6 days before admission, complained of nonproductive cough, chest pain for 3 days, followed by diffuse abdominal pain, nonbilious vomiting, and shortness of breath for 3-day duration.
Further history revealed no personal or family history of recent infection. The child denied any history of fever, rash, blisters, jaundice, and trauma. She had dysuria, but there was no history of oliguria or hematuria. There was no neurological history contributing to the diagnosis. She had neither weight loss, nor history of contact with tuberculosis. She was previously fit and well and vaccinated as per the national immunization schedule. At the time of presentation, she was hemodynamically unstable with tachycardia (heart rate: 147/min), hypotension (blood pressure: 82/54 mmHg), and had moderate respiratory distress (respiratory rate: 32/min). She was resuscitated as per the standard Pediatric Advanced Life Support guidelines. An emergency bedside two-dimensional (2D)-echocardiogram [Figure 1a and b] demonstrated a massive pericardial effusion with cardiac tamponade along with bilateral pleural effusions. Her chest X-ray demonstrated cardiomegaly and bilateral pleural effusions [Figure 2a].
She underwent an emergency pericardiocentesis under ketamine sedation, and we drained around 600 ml of hemorrhagic fluid. She also had bilateral chest drains placed for bilateral pleural effusions [Figure 2b]. The right-sided chest drain had drained around 1000 ml hemorrhagic fluid, whereas the left-sided chest drain had 900 ml drain in 24 h. A 2D echocardiogram postpericardiocentesis demonstrated the resolution of pericardial and pleural effusions and moderately impaired left ventricular function with an ejection fraction (EF) of 35% raising the possibility of myopericarditis.
The child was managed with supportive care including oxygen therapy, intravenous (IV) antibiotics, oral Ibuprofen, and IV Milrinone. She was commenced on steroids (IV methylprednisolone 30 mg/kg for 3 days followed by tapering dose of oral prednisolone for 2 weeks) in view of suspected underlying myopericarditis. She showed clinical improvement after 48 h of admission, and both the pleural and pericardial drains were removed after 5 days of intensive care unit admission. Her chest X-ray at discharge demonstrated normal cardiac contours and the resolution of bilateral pleural effusions [Figure 2c]. Workup of pleural fluid showed a packed cell volume of 20%, neutrophils of 85% with no evidence of malignant cells, and investigations for tuberculosis or any other bacterial etiology were negative. Investigations including computerized tomography chest and collagen profile were negative for malignancy and connective tissue disorders, respectively. However, the workup for possible viral etiology revealed a positive IgM titer for Coxsackie B viral infection. She made a full recovery and was discharged after 9 days of hospitalization. At discharge, her left ventricle showed normal function with an EF of 65%, and she had no recurrence of pericardial effusion during follow-up.