Idiopathic myocarditis involving the bundle of His.

The illness began with generalized abdominal pain and vomiting, accompanied by sore throat and headache. During the first night he had several attacks described as fits. On the second morning his pulse was 60 a minute and he appeared well, but that afternoon was again ill with abdominal pain and a heart rate of 40 a minute. He was admitted to the Children's Hospital, Sunderland. On initial examination the tongue was slightly furred, the throat inflamed, and the temperature 1010 F. The heart rate was 52 a minute and there was a blowing apical systolic murmur. Slight enlargement of the liver was present. He looked well and no anxiety was felt about his general condition, although the slow pulse rate caused much speculation. Enteric fever was considered and chloromycetin palmitate was given in doses of 250 mg. six-hourly. On the third day the lips were cyanosed and the liver was larger: his heart rate was about 40 beats a minute. Early on the fourth day he collapsed suddenly, with an irregular heart beat about 20 a minute, CheyneStokes respiration, a few basal crepitations, and a large tender liver. He had complete heart block, with partial right bundle-branch block, auricular rate 100, ventricular rate 28 a minute, and notched QRS complexes of 0-1 sec. duration. Thereafter he was nursed in an oxygen tent. Atropin was given without affecting the heart rate. He remained critically ill throughout the fourth day; there was constant cyanosis and bradycardia of 20-25 beats a minute. He had several short convulsions and vomited many times. A provisional diagnosis of Fiedler's myocarditis was made. Cortisone, 25 mg. six-hourly by intramuscular injection, made no obvious difference. The boy died on the morning of the fifth day. His previous history contained little significant information. He had been immunized against diphtheria at the age of 21 years and had had measles and whooping cough. His parents and three siblings were well. Throat swab showed neither hemolytic streptococci nor Corynbacterium diphtherik. Stool culture revealed no pathogens. Blood culture remained sterile. A blood count showed hemoglobin 10 8 g. per 100 ml.; W.B.C., 1600 per cu. mm.; differential count, neotrophils 76 per cent, lymphocytes 19 per cent, and monocytes 5 per cent. Chest X-ray and examination of spinal fluid gave normal results.