- You are evaluating a 12-year-old boy who has been fatigued for 2 weeks. His mother reports that he had an upper respiratory tract infection 2 weeks ago, and his appetite has been decreased since then. On physical examination, he is afebrile and has a heart rate at rest of 110 beats/min. His respiratory rate is 22 breaths/min. His lungs are clear, and he has a gallop rhythm without murmurs on cardiac auscultation. You discern hepatomegaly and mild jugular venous distention.
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Of the following, the MOST likely diagnosis is
A. anemia
B. dilated cardiomyopathy
C. Kawasaki disease
D. primary pulmonary hypertension - The gallop rhythm, hepatomegaly, and jugular venous distention described for the boy in the
vignette support the diagnosis of congestive heart failure (CHF), most likely due to myocardial
dysfunction associated with dilated cardiomyopathy. Generally, CHF is a clinical syndrome that
reflects the inability of the myocardium to meet the metabolic requirements of the body, including
those for growth. - The presentation in the older child differs from that of the young infant. In the
former, CHF usually presents with signs and symptoms of fatigue, particularly with exercise or
activity. In addition, children may present with shortness of breath, palpitations, diaphoresis, and
in the most acute cases, extremis. Almost invariably, the left ventricle is affected, and as its
systolic and diastolic function diminishes, its filling pressures increase. Clinically, this may
manifest during auscultation as a gallop rhythm. The increased left ventricular filling pressures
results in rising pressures in the pulmonary veins, pulmonary capillaries, pulmonary arteries,
right ventricle, and right atrium. When the right-sided filling pressures increase, the systemic
veins that drain into the right atrium, including those of the hepatic system and the jugular
system, become congested. Congestion of the former leads to hepatomegaly and that of the
latter may manifest with jugular venous distention discernible on examination. - Laboratory support for the myocardial failure seen in patients who have CHF can be
demonstrated by an elevation in the brain natriuretic peptide value. Results of this test almost
always are abnormal in patients who have significant CHF. - Among the many causes of CHF are large-volume left-to-right shunts with pulmonary
overcirculation, pressure load on the myocardium, inadequate blood flow to the myocardium,
infection or infiltration of the myocardium, or genetic or idiopathic diseases of the myocardium.
CHF from large-volume shunting lesions is seen almost exclusively during infancy. The other
causes may manifest any time throughout infancy, childhood, or adolescence. - Anemia can lead to a “high-output” state but does not present with the right heart failure
demonstrated by the patient in the vignette. Although Kawasaki disease can present in some
cases with CHF due to acute myocarditis, the patient in the vignette has no other physical
findings to support this diagnosis. Primary pulmonary hypertension is seen more typically in
females during adolescence or adulthood and includes the presence of a loud second heart
sound with or without a gallop rhythm. Pulmonary embolism typically presents more acutely with
chest pain, hypoxemia, and tachypnea in addition to the findings of acute right heart failure
Dr. Jayaprakash
Superintendent, ICH.
Institute of Child Health.
Gov. Medical College Kottayam.
Kerala, India.