Myocarditis and pericarditis — structured clinical encounter

Encounter structure

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

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]

2. 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]

3. 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]}

4. 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]

5. 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]