Pediatric Pearls: Tachycardia Out of Proportion
Ilene Claudius MD, Sol Behar MD, James Salway MD and Liza Kearl MD
Take Home Points
- Tachycardia out of proportion may be a sign of myocarditis.
- Viral myocarditis may present with subtle findings and over half of cases are missed on their first presentation.
- Patients with myocarditis should be dispositioned to the PICU as they are at risk of dysrhythmias and rapid decompensation.
- CASE. A 5 month old female presented with respiratory distress for a day. The mother reported the baby had decreased wet diapers and decreased oral intake over the previous two weeks. The mother had noticed blue lips, increased work of breathing and fever during the last two days. She took the child to the pediatrician the day before presentation and received a diagnosis of viral syndrome.
- The patient had been seen by her primary care provider two weeks prior with similar symptoms. She was given a 5 day course of azithromycin.
- She had no past medical history. She was a full-term child. Her vaccinations were all up-to-date.
- Vital signs. Her heart rate was 185. The blood pressure was 90/60. Respiratory rate was 48. The temperature was 99 F and the oxygen saturation was 100% on room air. The lung exam was unremarkable.
- The majority of these cases are bronchiolitis. What features of this case suggest something else?The patient had disproportionate tachycardia. The child had been ill for two weeks but had only been febrile for two days. With most viruses, fevers are seen early in the disease course. In this situation, the fever developed later.
- As a general rule of thumb, for every degree above normal, the heart rate should increase by about 7-10 beats. In this case, the child was afebrile but was very tachycardic.
- Normal vital signs in pediatric patients.