title: The challenges of prompt identification and resuscitation in children with acute fulminant myocarditis: case series and review of the literature.
abstract: OBJECTIVE
  To describe the clinical presentation, triage, resuscitation and outcome of acute fulminant myocarditis in children presenting to district hospitals and referred for cardiac intensive care.
  
  
  METHODS
  Case series describing five patients (from 2 weeks to 12 years old) with a diagnosis of acute fulminant myocarditis, presented to outlying hospitals between December 2006 and December 2007 and retrieved to a cardiac intensive care unit.
  
  
  RESULTS
  All children were admitted with non-specific symptoms such as vomiting, cough and poor feeding to their local hospital, where various provisional diagnoses such as viral gastroenteritis, bronchitis or renal failure were considered. Acute physiological deterioration usually prompted the referral for intensive care. Two children died at the referring hospital during stabilisation by the retrieval team. Three children survived transport to intensive care and to hospital discharge; two received mechanical support and one underwent urgent orthotopic heart transplantation. Enterovirus and parvovirus were identified as causative agents in two patients. In one case, macrophage activation syndrome was diagnosed although no clear viral trigger was identified. Median length of hospitalisation among survivors was 33 days, and mechanical cardiac support was required for a median of 12 days.
  
  
  CONCLUSIONS
  The diagnosis and initial management of acute fulminant myocarditis is extremely challenging. Prognosis for patients admitted to a cardiac centre for early mechanical support can be very favourable, while a delay in considering the diagnosis may result in poor outcome. The diagnosis of myocarditis should be considered in any previously well child presenting with a viral prodrome and non-specific organ dysfunction associated with dysrhythmias, shock or acute heart failure, even in the absence of cardiomegaly.
authors.affiliation: Cardiac Intensive Care Unit, Great Ormond Street Hospital and Children's Acute Transport Service, London, UK.
authors.forename: Geethanjali
authors.initials: G
authors.lastname: Ramachandra
authors.forename: Lynn
authors.initials: L
authors.lastname: Shields
authors.forename: Katherine
authors.initials: K
authors.lastname: Brown
authors.forename: Padmanabhan
authors.initials: P
authors.lastname: Ramnarayan
mesh_terms: D000208:Acute Disease; D002648:Child; D002675:Child, Preschool; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009205:Myocarditis / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D012151:Resuscitation; D012196:Review Literature as Topic; D014218:Triage