Young at heart

Recently I examined a teenaged boy with fever, muscles aches, headaches and intermittent vomiting. There were no signs of meningitis, no respiratory complaints but persistent high fevers despite acetaminophen and ibuprofen. The labs tests were not helpful. I sent a sample of blood for testing for Lyme disease and started amoxicillin for presumed Lyme disease. In much of the New England, Lyme disease has become prevalent.

Fast forward 2 days, and this polite and well spoken young man is back in the ER with his mother. A non-productive cough and significant shortness of breath have developed. One of my partners has examined the patient and we meet at the x-ray screen. The chest x-ray shows an enlarged heart and signs of congestive heart failure. My partner performs an ultrasound of the heart showing poor motion of the heart muscle and fluid around the heart in the pericardial sac.

The patient was tranferred to a pediatric CCU in a major teaching hospital. The presumptive diagnosis was myocarditis. Inflammation of the myocardium can be caused by infection, toxins and immunological disorders. Viruses especially coxsackie B and echovirus are the most common infectious agents. Parasites, protozoans, bacteria and fungi may also cause myocarditis.

Toxins that cause myocarditis include clozapine, an atypical antipsychotic used to treat schizophrenia. Cocaine is a direct myocardial toxin as well as a vasoconstrictor that can precipitate an MI (heart attack). A number of immunological disease such as sardcoidosis, rheumatoid arthritis and lupus cause myocarditis.

Chest pain in young patients rarely occurs from coronary artery disease. Kawasaki disease is a complex condition that may include injury to the coronary arteries in children. Pericarditis, inflammation of the membranes that cover the and enclose the heart, also presents with chest pain in young people. The etiology of pericarditis includes infections, medications, immunological and metabolic disorders.

The title of this blog relates to the fact that this patient was, is and will remain in my "heart". Doctors enjoy discussing unusual and challenging patients and diseases. This patient definitely falls into the category of a "great case". I try to connect with all of patients. Having been at the same hospital for most of my career, it is common for me to see patients and/or their family members more than once. Each shift I seek out "the one". A patient who breaks through the 30 years of EM cases and touches my cynical soul. This was the first time that I met this patient and his mother. He and I spoke about entering high school in September. We reside in the same town. He was "the one".

Emergency medicine is all about the moment. ER staff rarely gets follow up information concerning patients who are tranferred to other hospitals. The immediacy of EM has always been a great part of my career choice. The lack of follow up is a source of frustration. I will hope for a good outcome for this young man.

Another week begins. Another 20-30 patients to be examined and treated per shift. Another search for "the one".