What is the cause of these cardiac abnormalities?


Chyi-Sen Wu, MD, Chia-Wai Chang, MD, and Kong-Sang Wan, MD, PhD 
Taipei City Hospital, Taiwan

pericardial effusionTHE CASE: A 13-year-old girl is admitted to the inpatient cardiology unit because of progressive dyspnea. She has a history of shortness of breath off and on for the past 2 months, and her symptoms are worse on the day of admission. She reports having general malaise, insomnia, a 10-kg weight loss, and amenorrhea for the past 4 months. She has no known drug allergies; her immunizations are up-to-date.

On examination, the patient appears anxious. Ear, eye, nose, and throat findings are unremarkable. Chest expansion is symmetrical, with clear breathing sounds. Heart rate is 150 beats per minute. A grade 3 to 4/6 systolic murmur is audible over the left sternal border fourth to fifth intercostal space. Her extremities are freely movable without edema.

An ECG shows sinus tachycardia, with a heart rate of 130 beats per minute. A chest film on admission reveals cardiomegaly with pericardial effusion (A). Echocardiography confirms the cardiomegaly with compromised systolic function (left ventricular ejection fraction of 43.4%), massive pericardial effusion (greater than 10 mm), and moderate to severe mitral regurgitation with pulmonary hypertension (37.9 mm Hg) (B). The patient is treated with high-dose intravenous corticosteroids; however, her symptoms progressively worsen.


What might be the cause of the cardiac abnormalities in this patient?

  •  Myocarditis
  •  Cardiopulmonary or metastatic malignancy
  •  Autoimmune disease
  •  Metabolic disorder


(Answer on next page)


what an interesting presentation

The fact that her symptoms progressively worsened after treatment with high dose iv steroids

deflected my choice of autoimmune disease.

"When in doubt, 'Charlie' out"! ;-)

"When in doubt, 'Charlie' out"! ;-)

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