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+A 5-year-old Caucasian male presented to the Children’s Emergency Department with epistaxis, bleeding from the dental extraction site and a widespread purpuric rash, secondary to acute idiopathic thrombocytopenia.
+Two days prior to this, he developed a generalised chickenpox rash.
+While in the department it was noted that his heart rate ranged between 50 and 60 beats per min, he was otherwise haemo-dynamically stable with a normal blood pressure and oxygen saturations in air.
+He had a short systolic murmur grade 2/6 at the left sternal border.
+He had no clinical evidence of myocarditis or heart failure.
+He had extensive generalised petechiae and purpuric rash (figure 1) secondary to acute thrombocytopenia presumed to be due to varicella infection.
+Apparently he was healthy prior to this admission.
+There was no history of maternal lupus.
+An ECG was performed which showed complete heart block (figure 2).
+He was admitted to the high dependency unit for close overnight monitoring.
+The presumed diagnosis was complete heart block secondary to varicella infection.1 2 The initial investigation showed normal electrolytes, calcium, phosphate, glucose and magnesium levels.
+The full blood count showed a normal haemoglobin and white cell count.
+But the platelet count was low that is, 13×109/l.
+The platelet count normalised within 10 days without any intervention.
+The antinuclear antibody titres and the autoimmune screen were negative.
+Maternal autoimmune screen was negative.
+The echocardiogram showed a structurally normal heart and follow-up 24 h tape showed persistence of complete heart block.
+Following these investigations a diagnosis of congenital complete heart block was made.
+On follow-up after 6 months his heart rate remains between 50 and 60 beats per min, but he remains asymptomatic without any intervention.
+The need for a pacemaker is being considered on follow-up.
+The incidental finding of complete heart block was congenital in aetiology with no association with varicella infection or acute thrombocytopenia.
+This case highlights that asymptomatic late-presenting congenital complete heart block must be considered as a differential diagnosis in children presenting with asymptomatic bradycardia to the emergency department.