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A seven-year-old male was brought by his mother for chest pain. History reveals compressive left chest pain since 2 days, of moderate intensity, with no calming factors, pain which seems circumscribed to the entire left chest ending just below shoulder. He declares feeling pain more at night when lying down (especially after eating much) but recently feels pain during the day too. No dyspnea. Pain lasts for some minutes then usually stops. There is a history of similar episodes of this pain over the last 2-3 months. The boy has a history of regurgitation for years though infrequent in the past year, and epistaxis for years as well. He is the second child and the only boy to his parents. There is no family history of similar chest pain, abnormal bleeding or other chronic condition. His blood group and Hb electrophoresis are unknown. The mum reports being of blood group O rhesus negative (always injected with anti-D immunoglobulins after delivery) and HbAA.
Deworming was done about 2 weeks ago and immunization is not up to date since the age of 1 year. Psychomotor development seems okay for age. He was lastly hospitalized last year for malaria. On clinical examination, he has no chest pain at the time, no dysphagia, has lower abdominal pain, last stool the previous day, and enuresis. Urine colour is clear yellow.
He is well looking. Weight:25kg. Respiratory rate: 16cpm, Heart rate: 60bpm irregularly irregular. Well coloured. No palpable lymphadenopathy. No printing of neck veins. Chest symmetric. Apex beat felt in left fourth intercostal space, about 1cm lateral to mid clavicular line. S1,S2 sounds present with no murmur or other added sounds.
Abdomen is non distended, non-tender, hepatomegaly 2 cm below costal margin, with no hepatojugular reflux. Percussion of abdomen with no unusual finding. Bowel sounds present and of normal intensity.
Pulses are felt symmetric and of normal intensity in limbs. Limbs are well coloured.
No strange pigmentation was noticed on skin.
The rest of physical examination was unremarkable.

STOP, THINK AND DIAGNOSE.

Diagnosis was an acute Coronary Artery Disease(CAD), Firstly, Angina Pectoris of etiology to be investigated.
Secondly Myocardial Infarction or other coronary artery disease.

Differential diagnosis: Acute Gastritis, Gastroesophageal Reflux disease (GERD), an underlying Diaphragmatic hernia.

#Probably, there could be an underlying hemophilia or other coagulopathy.

Work-ups as emergency:
Chest X-ray, ECG, FBC
The Chest X-ray was normal but ECG was not available in the health structure.
The opinion of a pediatric cardiologist was then sought and a heart ultrasound was included in the work-ups. Counseling was done and the patient was sent promptly to do the ECG and heart ultrasound.
Follow-up has not been ideal but feedback is expected soon.

KEY POINTS:
-The Coronary Artery Disease came first given the specific location of pain on left and the type of pain as squeezing and pressure type (compressive). The gastrointestinal symptoms are quite disturbing making one think it could be GERD yet GI symptoms are described in literature review of CAD as the perception of some patients with CAD. Eliminating a more urgent situation seems important here.
-How would you have proceeded with the above symptoms and signs?
-Based on the working diagnosis, what etiologies should be considered at this age?

-Quick reminder on Rhesus D-Negative mother and injection of anti-D IgG.

-Is Hemophilia likely?

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8 responses to “Acute Coronary Syndrome in a child 🤔⁉️ ”

  1. Dr Anubodem Felix avatar

    In a child of 7 years I will go for malfomative heart disease first that got deteriorated over time( only element in disfavor is absence of dyspnoea.
    2ndly, pleural pain from pleuritis(pleural effusion) likely a TB as etiology or other infectious community microbes
    3rdly, Coronary artery diseaee( more of a prinzmetal angina as there is no risk factor)
    4th cholangitis

    1. admin avatar

      Thanks very much for the insight Doctor. Interesting differentials. His pulmonary history and exam was really unremarkable…
      Thanks for citing Prinzmetal angina..worth noting among the CADs. Thanks.

  2. Germaine Mbange avatar

    Thank you very much for this wonderful case
    If a hemophilia is suspected I think I’m interrogation more questions should have been asked to slowly eliminate the diagnosis
    For example how was his circumcision ? Did he bleed too much history of prior transfusions?

    1. admin avatar

      Actually transfusion would have been mentioned if it was done. The only abnormal bleeding Mum has noticed has been the epistaxis. We are concerned if this is linked to the present disease or it’s just co-existing with it. It could be hemophilia or another anomaly in the coagulation pathway.

  3. TetuAl avatar

    Waoohhh a CAD at 7years would be very peculiar though not impossible. Prompting me to think to ask what risk factors did you find in him? Hypertension (pediatric BP cusp are available)?, blood cholesterol? Etc.

    Did you request for Hb electrophoresis so that wevare very certain he has no de novo sickle cell disease since mother is is AA …..could be a symptomatic HBAS too!

    Awaiting updates pls

  4. TetuAl avatar

    Waoohhh a CAD at 7years would be very peculiar though not impossible. Prompting me to think to ask what risk factors did you find in him? Hypertension (pediatric BP cusp are available)?, blood cholesterol? Etc.

    Did you request for Hb electrophoresis so that wevare very certain he has no de novo sickle cell disease since mother is is AA …..could be a symptomatic HBAS too!

    Awaiting updates pls

    1. admin avatar

      You’re right. No BP cusp. Hopefully there would soon be easy access to all such tools needed for physical examination.
      Wondering if a symptomatic AS would present with just this with no history of painful limbs as well. We are also seriously waiting for the update.

    2. Nfor Leonard avatar

      I agree with Dr Tetu

      We absolutely need a BP for this child.

      The fact that there is time locked response with food intake i would want to equally do a symptomatic treatment for GERD.
      An ECG at rest and Stress ECG will be very important.
      Equally Troponins during the episode of pains I think is important

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Acute Coronary Syndrome in a child 🤔⁉️