team challenge core concepts

1. Pediatric Chest Pain - Myocarditis

• Difficult diagnosis to make and often missed, occasionally with fatal consequences. Remain vigilant!
  
• ECG is most sensitive study, though still only 90% Sinus tachycardia may be only sign.
  
• Viral etiology most common, though can be bacterial, autoimmune or toxic.
  
• Treatment is supportive, with pediatric cardiology involvement early.
  
• Lyme carditis presents most commonly as complete heart block, complicating 1% of Lyme disease cases. 
  
• Other rare causes of carditis include Rickettsial disease, Chagas disease, Dengue fever, West Nile virus and Chikungunya. 
  

2. Neuroleptic Malignant Syndrome

• Multiple diagnostic criteria, but all have hyperthermia and muscle rigidity as core components. Other elements are altered mental status/agitation, autonomic instability, dyspnea, dysphagia and incontinence.
  
• Typical antipsychotics are the most frequent culprit, but can be seen with all antipsychotics as well several other medications. Also seen following withdrawal of Parkinsonian medications (L-dopa).
  
• Supportive care is paramount! Fluid resuscitate, cool patient and consider intubation/paralysis to prevent complications associated with severe muscle rigidity (rhabdomyolysis). Dantrolene/bromocriptine/amantadine discussed in literature, but secondary to symptomatic support.
  

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