Pediatric Myocarditis in a Community Pediatric Emergency Department: A Case Series

Acute fulminant myocarditis is rare but life-threatening and requires prompt recognition and intervention. Myocarditis presents variably, from nonspecific symptoms to severe arrhythmias and cardiogenic shock, complicating timely diagnosis. Community pediatric emergency departments (EDs) may be the first point of contact, necessitating high clinical suspicion among providers. This case series describes two cases of pediatric myocarditis within a six-month period at a community pediatric ED. Both cases illustrate the challenge of early recognition and the need for rapid stabilization and transfer to a tertiary care center in order to achieve favorable outcomes for these patients. Case 1 describes a 13-year-old female who presented with nausea, vomiting, and abdominal pain, later developing complete heart block. Immediate interventions, including pharmacologic support and transcutaneous pacing, stabilized her for transfer. She was diagnosed with acute fulminant viral myocarditis, required extracorporeal membrane oxygenation (ECMO), and was ultimately discharged. Case 2 demonstrates a 10-month-old male who presented after a brief unresponsive episode, which was initially suspected to be a seizure. He developed pulseless ventricular tachycardia requiring defibrillation and was transferred after stabilization. He was confirmed to have acute fulminant viral myocarditis requiring ECMO, then ultimate placement of a ventricular assist device and prolonged intensive care hospitalization, and he is now discharged. Both cases underscore the importance of maintaining myocarditis in the differential diagnoses for pediatric presentations that do not primarily suggest cardiac involvement. Effective use of phone consultations, shared electronic health records, and established transfer protocols facilitated timely interventions, demonstrating that community EDs can deliver high-quality care despite resource constraints. Pediatric myocarditis, though rare, necessitates rapid recognition and intervention by providers. Community pediatric EDs can significantly impact patient outcomes, highlighting the importance of preparedness for pediatric cardiac emergencies.