22665582 Visualization

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