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    Chest pain in child with persistent fever

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    As you review the boy's medical history, you see that the patient was healthy until about a week ago when he developed a fever to 38.9°C, sore throat, and headache. His parents took him to his pediatrician; they denied that he had cough, rhinorrhea, vomiting, or diarrhea. He hadn't had any recent travel or sick contacts at home. His pediatrician prescribed amoxicillin for presumed group A streptococcus (GAS) pharyngitis.

    Because his symptoms persisted, his parents took him back to the pediatrician 2 days later, where a throat culture was obtained. His antibiotic was changed to erythromycin for the unlikely possibility of penicillin-resistant GAS. He was sent home with instructions to complete a 1-week course of erythromycin. The throat culture subsequently grew GAS.

    Three days before coming to the ED last night, the boy had resolution of his sore throat, but he had persistent symptoms of fever and developed diffuse muscle aches without joint pain. His parents took him to see his pediatrician, were given reassurance, and were told to complete his course of antibiotics. Parental concern that the boy was not improving despite 7 days of 2 different antibiotics prompted them to bring him to the ED, where he was seen by your colleague.

    You explain your concerns with your ED colleague. The duration of the child's fever, although perhaps consistent with a self-limited viral infection, should make one consider other infectious etiologies. Also, the development of associated symptoms, although nonspecific, is of concern, particularly the onset of chest pain. Although the patient looked well enough to go home, you tell your colleague that evaluating for other infections as well as pulmonary and cardiac causes of the child's chest pain would have been prudent. You advise him to phone the family and ask them to bring the boy back for persistent or worsening symptoms.

    The patient returns to the ED, now 3 days after last being seen, and you are called to assess the patient. His fever and chest pain have only mildly improved with ibuprofen. Today his muscle aches have resolved, but his fever continues to 39.5°C, and the right-sided chest pain has worsened despite completing his antibiotic course 1 day ago. His chest pain seems to be aggravated when taking deep breaths and lying down. He rates his chest pain as severe, and he is having some difficulty breathing.

    Physical examination

    His physical exam is remarkable for being afebrile, with a heart rate of 120 beats per minute and normal blood pressure with good perfusion. He is tachypneic with a respiratory rate of 38 breaths per minute but without other signs of respiratory distress and an oxygen saturation of 98% on room air. His oropharynx is clear without lymphadenopathy. He has shallow breathing but lungs are clear to auscultation.

    He is tachycardic with regular rhythm, and no murmurs or rubs are appreciated. His skin is without rashes or lesions. He has no pain on palpation, including the chest wall. The remainder of his exam is unremarkable.

    You are concerned about pulmonary and cardiac processes. Pneumonia, parapneumonic processes, and carditis are all in your differential. You order a chest radiograph (CXR), electrocardiogram (ECG), and echocardiogram and send blood and urine for culture and screening labs to evaluate for infectious and inflammatory processes.

    Laboratory data are remarkable for the following: leukocyte count, 34,900/mm3; 87% polys, 4% bands; erythrocyte sedimentation rate (ESR), 104 mm/h; C-reactive protein (CRP), 22.9 mg/dL; antistreptolysin O (ASO) titer, 467 IU/mL (positive is >150); antinuclear antibody (ANA), negative; comprehensive metabolic panel, unremarkable. Chest x-ray shows moderate cardiomegaly, with left lower-lobe opacity. The ECG shows high-normal PR interval with ST segment elevation. The echocardiogram reveals a small posterior pericardial effusion with good function and no other clear abnormalities. The patient is admitted to the hospital for further evaluation and management.

    Differential diagnosis


    Table 1: Common causes of pericarditis
    Acute pericarditis is inflammation of the pericardial space that has numerous causes (Table 1).1 Infections, typically viral, are the most common cause in children.2 In our patient, this is a serious consideration given the presence of a possible viral prodrome of fever and myalgias, although the patient did not exhibit other symptoms of a viral infection such as rhinorrhea, congestion, or diarrhea. Ketorolac is started, because nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatments for viral pericarditis.

    Bacterial infections are also a consideration, but these patients are typically more ill appearing and deteriorate rapidly.

    Cefotaxime and clindamycin are initiated for possible bacterial pneumonia because of the left lower-lobe opacity on CXR. Tuberculosis is seen in high-risk patients from endemic areas, but that does not describe your patient.2 Infectious disease and cardiology consultants recommend an extensive evaluation for potential infectious etiologies (eg, viral, bacterial, or tuberculosis).

    A thorough evaluation does not yield any infectious etiology, which turns your focus to rheumatologic causes, also a common cause of pericarditis.3 The absence of arthritis makes juvenile rheumatoid arthritis less likely, although there can be a delay in its onset that may still manifest in this patient.4 A negative ANA and lack of other systemic clinical criteria make systemic lupus erythematosus unlikely.

    The history of GAS pharyngitis leads you to consider the diagnosis of acute rheumatic fever (ARF).5 The lack of other findings on history and examination excluded a number of other causes of pericarditis, turning our focus to ARF. Your patient fit the diagnosis of ARF based on Jones Criteria with the presence of 1 major (carditis) and 2 minor manifestations (fever and elevated acute-phase reactants) and with evidence of GAS infection (positive throat culture and elevated ASO titer).3 This patient presented with carditis including signs (pleuritic chest pain worse in the supine position) and findings (ST segment elevation on ECG and pericardial effusion on echocardiogram) of pericarditis.

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