Evaluation of the diagnostic work-up in children with myocarditis and idiopathic dilated cardiomyopathy.

The underlying etiology of dilated cardiomyopathy (DCM) in children varies, 14-22% is secondary to myocarditis, and the majority remains idiopathic. Etiology has prognostic value; however, 'a clinical diagnosis of myocarditis' has been frequently used because the gold standard [endomyocardial biopsy (EMB)] is often not performed. Therefore, a consistent diagnostic approach and interpretation is needed. In this multicenter study, we evaluated the diagnostic approach and interpretation of the viral results in children with myocarditis and idiopathic DCM. We included 150 children with DCM, of whom 103 were assigned the diagnosis myocarditis (n = 21) or idiopathic DCM (n = 82) by the attending physician. Viral tests were performed in 97/103 patients, in only 34% (n = 35) some of the tests were positive. Of those patients, we evaluated the probability of the assigned diagnosis using the viral test results. We classified viral test results as reflecting definite or probable myocarditis in 14 children and possible or unlikely myocarditis in 21 children. Based on this classification, 23% of patients were misclassified. We found that in children with DCM, the diagnostic approach varied and the interpretation was mainly based on viral results. Since a 'clinical diagnosis of myocarditis' has been frequently used in daily practice because of the lack of EMB results, a uniform protocol is needed. We propose to use viral test results in several steps (blood PCR, serology, PCR and/or cultures of the gastro-intestinal and respiratory tract, and EMB results) to estimate the probability of myocarditis.

Bullous lesions in Henoch Schönlein Purpura as indication to start systemic prednisone.

UNLABELLED: Henoch Schönlein Purpura (HSP) is usually mild and self-limiting, but it may be accompanied by severe complications such as bullous lesions. We describe the use of systemic prednisone in two patients with bullous lesions in HSP. The first patient presented with progressive bullous lesions distributed on the limbs that evolved into painful ulcers and necrosis. These were further complicated by a secondary skin infection. He then received 1 mg/kg/day prednisone after 9 days. Patient 2, a 10-year-old boy, presented with HSP and bullous lesions and received intravenous prednisone 1 mg/kg/day within 48 h after appearance of the bullous lesions. He recovered rapidly without any complications. CONCLUSION: To reduce the severity of HSP related bullous lesions and their sequelae, we would propose starting prednisone (1 mg/kg/day) as soon as the bullae appear. In addition to prednisone, analgesics and specialist skin care for bullae should be started.