Case of Urticaria and Arrhythmia, 13 y/o

[corpsmanUP]

Lets talk some medicine. I worked yesterday at my PA job because my preceptor took off since we are working the weekend. So I was seeing mostly colds and hypertension refills, diabetic checks, etc...etc....etc.. like always in FP. My supervising doc took the day off too since I came in and I had the patients alone...nothing new. I had a 13 y/o girl come in for a "rash" x 3 days than had not responded to Benadryl. She had no other symptoms or complaints except for the itching. She had been to school that day, participated in PE, didn't have any trouble breathing...nothing. It was almost one of those cases where I could see a doc/PA literally just handing them a script for some antihistamines and/or some Prednisone and sending her out. But the edema on her neck and chest was noticeable "thick" almost giving her webbed neck appearance. I have seen her many times before so I knew her baseline based on my previous notes. The shocker came when I listened to her heart. I could not make heads or tails of the cycle at all. I tried coordinating with peripheral pulses, but it seemed like there was a cycle of strong, weak, weaker, strong, weak, weaker......in triplets. But still I could not hear the s1s2 associated with the 2 weak beats at all. The chest wall had a serious lift asscociated with the 2 cycles of weaker beats also.

She had just recovered from a "cold" last week. My last exam of her revealed a normal CV exam, 6 months ago. Her BP was stable, and the rest of her exam was not impressive except for the thick/ropy erythematous edema that had raised patches resembling urticaria. She had no known food or medication exposures.

I had the MA do an ECG on her and it showed bigeminal couplets with an underlying normal axis and rate. I called the ED at the Children's Hospital in my city and told them I was sending her there...mostly so she wouldn't get triaged into the corner of the waiting room. The family did not want to take her by ambulance but the ED doc told me it was all on me until she got there then. I accepted that because she was "stable", and because I knew if I pissed off the non-insured parents that they might just take her home. It was hard to convince them that she needed to go and I had worked hard to convince them to go. An ambulance to them equalled more expenses and they were not doing it. So I had a tight sphincter for about 30 minutes as I prayed this little girl wouldn't go into V-tach on her way. Her mom called me when she got to the ED and I breathed a sigh of relief!!

Any ideas??? I initially was thinking viral myocarditis or perhaps some sort of later stage spirochetal infection of the conducting system. I try to keep the differential broad with urticaria because the list is literally miles long of the causes. I've seen it in thyroid storm, occult cancers, meds, foods, chemicals, and many other things. I just don't know. But I'll find out today and give a follow up hopefully.

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[krust3]

any fever? was she hypotensive? abnormal lung sounds? any arthralgias?

 

[spyderdoc]

Yeah, I agree. Sounds like it could be a myocaarditis. Another thing to consider would be a big mediastinal mass (lymphoma/thymoma/thyroid) that could be causing an SVC syndrome since she had this head/neck edema....

 

[ERMudPhud]

Its always hard when you don't see the rash and the rest of the case yourself. This is one of those where you are probably going to be glad you have a tertiary referral center to send the kid to. I had a few ideas. The description of the rash sounds a lot like EM minor (thick, ropy, raised, erythematous). Any joint symptoms or mucous membrane involvement? I think you are on the right track already. EM is commonly associated with viral infections and a viral myocarditis could give you the EKG changes you have described. Was there an enlarged heart on CXR? Lyme disease gives conduction disease and a rash that can sometimes be EM like. I'm not sure conduction disease would give you that much ectopy though. I usually think more in terms of heart block etc... Is Lyme endemic in your area?

The only other thing I could think of off the top of my head was acute rheumatic fever. You have potentially two of the major criteria, carditis and erythema marginatum. Could her "cold" have been a strep infection?

Let us know the final diagnosis but I would be surprised if they have the whole answer in 24 hours.

Cool case

 

[sweetfynesse]

gosh, there's a long differential for urticaria, although it's difficult to know if this rash was truly urticaria or another manisfestion of the skin. based on the rash and conduction abnormality, i'm thinking more lyme or viral myocarditis vs rheumatic fever (but I'm not hearing about any other major or minor criteria for RF in your exam)...anyway, let us know what you find out

 

[southerndoc]

Was she on any medicines besides diphenhydramine? Fever, other associated symptoms? Was the rash truly urticarial looking and couldn't possibly be erythema migrans (usually doesn't itch, but can)?

Generally urticaria and myocarditis can be caused by drugs or infection. Usually viral etiologies will not present with urticaria, but protozoal can. Some of the things to rule out include VLM (has she had any contact with pets or been eating dirt?) or more specifically, trichinosis, which can cause substantial conduction defects. Trichinosis can cause marked urticaria.

You can get myocarditis from Stevens-Johnson syndrome. Could this have been erythema multiforme type leasions you were seeing?

The edema you saw on her neck and chest might have been due to increase right ventricular leading to increase right atrial pressures, thereby increasing the SVC/IVC pressures causing a "back up" of the blood and interstitial fluids. Was there evidence that she could have had a tamponade situation developing?

Of course, the simplest explanation is usually the one that's right: this is probably a viral myocarditis, but the zebras should be tossed around.

 

[corpsmanUP]

Was she on any medicines besides diphenhydramine? Fever, other associated symptoms? Was the rash truly urticarial looking and couldn't possibly be erythema migrans (usually doesn't itch, but can)?

Generally urticaria and myocarditis can be caused by drugs or infection. Usually viral etiologies will not present with urticaria, but protozoal can. Some of the things to rule out include VLM (has she had any contact with pets or been eating dirt?) or more specifically, trichinosis, which can cause substantial conduction defects. Trichinosis can cause marked urticaria.

You can get myocarditis from Stevens-Johnson syndrome. Could this have been erythema multiforme type leasions you were seeing?

The edema you saw on her neck and chest might have been due to increase right ventricular leading to increase right atrial pressures, thereby increasing the SVC/IVC pressures causing a "back up" of the blood and interstitial fluids. Was there evidence that she could have had a tamponade situation developing?

Of course, the simplest explanation is usually the one that's right: this is probably a viral myocarditis, but the zebras should be tossed around.

I've never seen marginatum, but I have seen both EM minor and major. It was neither. She had no "real" fever at 99.6. I doubt it was a tamonade...she had no JVD, and the voltage as measured was actually on the high side. You should have seen these PVC's...they were almost coming off the sheet! It was definitely not a Lymes looking rash, and I don't think we have had a real case of Lymes in Texas. Most of the reported cases of Lymes are reported from quackpots who treat chronic fatigue and fibromyalgia and blame it all on Lymes. Her BP was normal, and her lungs were clear. It was not actually classif urticaria though. It was mostly just edematous, red skin from the lower neck to the shoulders and to the xiphoid. It spared pretty much everywhere else. She said she had some on her thighs but I didn't make her take her jeans off because I was worried about her heart by then. I should have told you that she was Mexican and like everyone I treat she likely had been out of the country recently. I'll do my best to get some prelim answers tomorrow and post again.

 

[fuegofrio17]

I'll throw Chagas up on the zebra differential. It would also be interesting to see what the CBC eventually showed (any thrombocytopenia or schistocytes?). Btw--what part of Texas are you in Corpsman?

 

[Homunculus]

vaccinations up to date??

definitely smells viral to me.

--your friendly neighborhood pediatric Occam's Razor using caveman

 

[southerndoc]

I'll throw Chagas up on the zebra differential. It would also be interesting to see what the CBC eventually showed (any thrombocytopenia or schistocytes?). Btw--what part of Texas are you in Corpsman?

I agree with the Chagas suggestion. Trypanasoma cruzi is relatively common in Mexico.

 

[Homunculus]

update?

--your friendly neighborhood curious caveman

 

[southerndoc]

Yea really, what was the diagnosis?

 

[corpsmanUP]

Yea really, what was the diagnosis?

I truly wish I had something interesting to pass on but I don't. I called the mother a couple of days ago and she said that they released her daughter about 5 days after I sent her to the ED. They simply sent her home on an antiarrythmic and no diagnosis except to say that she may have "always had it". I don't buy it with the severe edema in the chest and neck. Totally weird! By the way, I told you wrong on the rhythm....I had meant to say she was having bigeminal couplets, not bigeminy alone. I think some of the viral cultures will end up showing something and I am requesting her inpatient record to be sent to the office. I'll keep you posted I promise. FYI, I sent her to Cooke's Children's Hospital, one of the states' best.

 

[southerndoc]

I'll keep you posted I promise.

Dude you already let us down!

 

[Bernardo_11]

How much Benadryl was the mother giving the child? Diphenhydramine, or any other antihistamines, have been known to cause some bad cases of arrhtymias. I remember seeing a case presented by a Peds ER doc where the child had an arrhythmia after putting benadryl lotion onto her open sores. Perhaps your child's arrythmia was caused by the benadryl and it went away... or a benadryl overdose caused an exacerbation of a pre-existing condition. Nevertheless, I hope this child is being followed by a peds cardiologist.

Nice case though... should have been posted in the peds forum.

Nardo
DB Peds Fellow

 

[corpsmanUP]

How much Benadryl was the mother giving the child? Diphenhydramine, or any other antihistamines, have been known to cause some bad cases of arrhtymias. I remember seeing a case presented by a Peds ER doc where the child had an arrhythmia after putting benadryl lotion onto her open sores. Perhaps your child's arrythmia was caused by the benadryl and it went away... or a benadryl overdose caused an exacerbation of a pre-existing condition. Nevertheless, I hope this child is being followed by a peds cardiologist.

Nice case though... should have been posted in the peds forum.

Nardo
DB Peds Fellow

Excellent thought...hadn't thought of that. Being nearly a week in one of the nation's premier children's hospitals I would feel comfortable saying she saw Peds cards. I doubt a general peds doc is going to send someone home on an antiarrhythmic.