• A previously healthy five month old male presented with widespread raised, crusted, erythematous, vesicular lesions. These lesions were first noted around  his  mouth and chin area. The patient had been diagnosed with impetigo and prescribed Keflex as an outpatient. He was given his oral antibiotic but the  lesions progressed to involve his eyelids, ears, trunk and extremities. Many of these lesions were clustered together. We admitted the patient for further evaluation and treatment of his eczema herpeticum. Initial treatment included IV Clindamycin and Acyclovir after appropriate cultures from a fresh lesion were obtained. The bacterial culture did not suggest secondary impetiginization so the Clindamycin was discontinued at the suggestion of our ID consult. Herpes culture and DFA were both positive for HSV 1. We transitioned him to oral Acyclovir to finish a total of ten-day treatment. He was discharged home with close follow-up with his pediatrician, dermatologist, and infectious disease specialists.

• A seven week-old breast fed male presented to an outside emergency department with a two day history of diffusely spreading, erythematous, non-blanching, purpuric rash. The rash started the morning after his mother had halibut for dinner. The baby was noted to have diffuse edema upon arrival to the pediatric ward  The patient’s erythematous rash developed throughout that day from diffuse purpura to urticarial in appearance. Blood, urine, and CSF cultures remained negative. A diagnosis of acute hemorrhagic edema of infancy was made. Oral Benadryl helped with decreasing swelling and erythema during hospitalization. The rash resolved on the day of discharge and he was sent home with close follow-up with his pediatrician and dermatologist.
  
  
• A previously healthy thirteen year old male presented to an outside hospital with sudden onset of epigastric abdominal pain and vomiting. The pain developed acutely, approximately 10 hours after he sustained trauma to his abdomen during a basketball game. The patient described his pain as a sharp, stabbing, mid-epigastric pain without radiation. His liver transaminases, pancreatic enzymes, and hematocrit were all stable. A CT scan of the abdomen showed no evidence of acute hemorrhage, but did reveal a small 3 cm x 3 cm cyst in the area of mid-duodenum.  We admitted the patient for evaluation and management of his duodenal hematoma. The patient was made npo with placement of a nasogastric tube to low continuous suction. His pain was managed with IV narcotics. A repeat CT scan of the abdomen was performed at the suggestion of the pediatric surgeons to monitor progression of the hematoma. He did not have any evidence of acute bleeding but was transferred to another hospital for further management by a trauma surgery team.
  
  
• A previously healthy fourteen year old male presented to an outside hospital with acute onset of chest pain. The patient awoke on the morning of admission with sudden onset of sharp, mid-sternal, non-radiating chest pain. His pain fluctuated throughout the day and was noted to improve with sitting forward and worsen with lying down.  At the outside emergency department, his EKG was notable for diffuse ST segment elevation. His cardiac enzymes were also elevated (CKMB = 9 and Troponin I = 5.06). We transferred him to our intensive care unit for further evaluation of myopericarditis. The initial echocardiogram did not reveal a pericardial effusion or coronary artery blockage. We started him on Ibuprofen to decrease the inflammation and closely followed his cardiac enzymes. His peak values for the admission were CKMB = 115.9 and Troponin I = 35.25. He subsequently developed a small pericardial effusion without evidence of cardiac function compromise. His cardiac enzymes and EKG changes normalized by the time of discharge. We discharged him with Ibuprofen and close follow up with his primary physician and cardiologist.

Acute pericarditis can present with chest pain, pericardial friction rub, electrocardiogram (ECG) changes, and pericardial effusion. The presence of at least two of the above mentioned clinical findings are required to make the diagnosis. In addition, an elevated white blood cell count, ESR, and most importantly, CRP correlate with this intense inflammatory process.

The chest pain of acute pericarditis is of sudden onset. It tends to be a sharp anterior chest pain which is exacerbated with deep inspiration. The pain may be relieved with sitting up and leaning forward. Other causes of chest pain such as myocardial ischemia, pulmonary embolism, gastroesophageal reflux, and musculoskeletal pain should also be considered in the differential diagnosis.

A pericardial friction rub is a highly specific for this disease. The rub can vary in intensity and appear and disappear over a few hours, thus making the sensitivity variable depending on the timing of auscultation. The rub is often best appreciated over the left sternal border, but can also be widespread. The intensity increases as the patient leans forward or against their elbows and knees. This latter position increases contact between the inflamed visceral and parietal layers of the pericardium.

There are four stages of ECG changes which represent inflammation of the epicardium. The first stage is characterized by diffuse ST segment elevation. The PR segment can show depression in leads V5 and V6 but elevation in lead aVR. The second stage is characterized by resolution and normalization of the ST and PR segment changes. Generalized T wave inversions can be seen during the third stage. The last stage is characterized by either normalization of the T wave inversions or persistence of these T wave changes in patients with chronic pericarditis. Sustained atrial or ventricular arrhythmias are rare in acute pericarditis and should prompt consideration of myocarditis. Myopericarditis should be considered when there is significant involvement of the myocardium or acute coronary syndrome.

Elevated biomarkers of myocardial necrosis, such as creatinine kinase (CK-MB) and cardiac troponin I (cTnI), can be seen in both acute pericarditis and myocarditis . Young male patients with a recent infection and pericardial effusion tend to have elevated cTnI levels. Elevation of the cTnI above 1.5 microg/L is often seen with ST segment elevation. This elevation usually resolves after one week and does not increase the risk of complications. The chest radiograph can be normal. A new finding of cardiomegaly can be seen after accumulation of 200ml of pericardial fluid.