The Girl with Persistent Fevers and Lethargy

The child presented with a fever up to 38.4ºC, blood pressure of 80/50 mm Hg, and lethargy. Physical exam revealed conjunctival injection of both eyes, warm skin, and a blanching macular rash. Laboratory testing showed elevated inflammatory markers, hyponatremia, anemia, and leukocytosis; chest radiography showed bilateral interstitial edema. Fluid resuscitation did not improve her blood pressure. She then developed cool extremities, delayed capillary refill, and wide-complex tachycardia (Figure 1), making it increasingly clear the patient was in cardiogenic shock. Epinephrine and milrinone were initiated, cardiac biomarkers were observed to be elevated, and Coxsackie B–specific IgM antibodies were detected. A diagnosis of myocarditis from …