Case Report

Kepada Yth.

Non -Infection Unit

DILATED CARDIOMYOPATHY
Presenter

: Gouthami Katan(100100260)

Day/Date

: Friday/ May 9th 2014

Supervisor

: dr. Tina Christina.L.Tobing, Sp.A(K)

Introduction
Heart is a powerful pump made of muscle (myocardium). It is divided into four
chambers: the upper two atria are the receiving chambers and the lower two ventricles are the
pumping chambers.2
Dilated cardiomyopathy (DCM) causes the heart to become enlarged, particularly the
left ventricle, and to function (squeeze and pump) poorly. As a result, the heart muscle
becomes weak and thin and is unable to pump blood efficiently around the body. This causes
fluid to build up in the lungs, which become congested, and results in a feeling of
breathlessness. This condition is called "left heart failure." Often there is also right heart
failure, which causes fluid to accumulate in the tissues and organs of the body, usually the
legs and ankles, and the liver and abdomen.2
This is the most common form of cardiomyopathy and it affects about 6 per million
children each year. Dilated cardiomyopathy (DCM) occurs when disease affected muscle
fibers are enlarged or stretched (dilated) in one or more chambers of the heart. Usually, the
enlargement begins in one of the two lower pumping chambers (left ventricle) and then
proceeds to the heart's upper chambers (atria) as the condition progresses. Eventually over
time, all four of the heart's chambers are affected as the heart tries to "compensate" its
weakened condition and poor contraction by further stretching. A possible complication is
when the valves (mitral or tricuspid) between the upper chambers (atrium) and lower
chambers (ventricles) also enlarge. As the heart enlarges, it decreases its efficiency in
pumping blood through the body. When the disease progresses to congestive heart failure,
fluid can build up in the lungs, liver, abdomen and lower legs.1

The aim of the paper is to report a case of dilated cardiomyopathy in a 14 year girl.

CASE REPORT
Name

: AAM

Age

: 14years

Sex

: Female

Date of Admission

: April 29th, 2014

AAM, female, 14 years old, Indonesian, admitted to Haji Adam Malik General Hospital on
29th April 2014 with shortness of breath. She has been experiencing shortness of breath for
the past one month. Her condition has been worsen in this two weeks and related to activity.
She can get easily tired since 5 years old. She have history of continous fever and cough in
the past one month. She also have been experiencing joint pain in the last four month.
Decrease in body weight was found in this four months. The patient have been seen pale in
this four month and there is no bleeding found. History of constipation was found for two
days.
Before she was admitted to Adam Malik General Hospital, she was treated by a pediatrician
in Bunda Thambrin Hospital with dilated cardiomyopathy and minimal pulmonary embolus.
Later she was referred to Adam Malik General Hospital for further treatment.
History of previous illness
: Cardiomyopathy and minimal pulmonary embolus
History of previous medications : Propranolol, Aldactone, Digoxin
History of labor
: Normal delivery, cried as soon as baby was born, no
cyanosis
History of growth and
Development
: Growth and development when toddler
suitable with toddler in same age.
History of immunization
: complete immunization

Physical examination

Presens status
Sensorium
Temperature
Heart Rate

: Alert
: 37,5C
: 110 bpm, regular, murmur (-)

Respiratory Rate

: 72 x/minute, regular, rales (-)

Blood Pressure

: 80/50 mmHg normal

Weight

: 28 kg BW/A = 53.85% severe malnutrition

Height

: 146 cm BH/A = 90.12% normal

Nutrition Status

: BW/BH = 71.80% Severe malnutrion

Anemic and dyspnea was found while cyanosis,icteric and edema were not found.
Localized Status
Skin

Pale

Head

Old man face (+)

Eyes

Light reflex: (+/+), pupils were isochoric, pale of conjunctiva palpebra

Nose

inferior (+/+)
Normal in appearance

Ear

Normal in appearance

Tounge/

Normal in appearance

Teeth
Tonsil/

Normal in appearance

Pharynx
Neck

Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiform, retraction(+), distinct intercostal space

HR: 110 bpm, regular, murmur (-) soft heart sound

Abdomen

RR: 68 rpm, regular, rales (-/-)

Soft , peristaltic (+) normal, liver and spleen: not palpable

Extremitie

Pulse 110 bpm, regular, p/v was adequate, warm extremities, CRT <3

Hypotropy muscle (+), loss of subcutaneous fat (+)

Genitalia

, normal in appearance.

Laboratory finding on April 27th 2014:

Complete Blood Count
Hematology
Hemoglobin (HGB)

Unit
g%

Result
11.6

Reference
12.0-14.4

Erythrocyte (RBC)
Leucocyte (WBC)
Hematocrite
Erythrocyte
sedimentation

106/mm3
103/mm3
%
mm/hou

4.54
5.240
35.1
23

4.75-4.85
4.5-11.0
36-42
0-20

rate
Thrombocyte (PLT)
MCV
MCH
MCHC
RDW
MPV

r
103/mm3
fl
pg
g%
%
fl

351
77.4
25.7
33.2
18.0
6.14

150-450
75-87
25-31
33-35
11.6-14.8
7.0-10.2

61.7
26.4
11.8
0.113
0.01

37-80
20-40
2-8
1-6
0-1

Difftel Count
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil

%
%
%
%
%

Echocardiography results on April 28th 2014:

Conclusion: Dilated cardiomyopathy , moderate MR, mild TR and minimal pulmonary
embolus
Working Diagnosis: CHF ec moderate TR + dilated cardiomyopathy + minimal PE + severe
malnutrition.
Management :

Total bed rest

Semi fowler position
O2 1-2 l/i nasal canule
IVFD D5% 4gtt/micro
Inj.Lasix 30mg/12jam/IV
Propanolol 3 x 20 mg
Aldactone 2 x 12.5 mg
Digoxin 2 x 0.14 mg
Multivitamin without Fe
Lacfolac syrup
Folic acid
Diet F75 250cc/3h + 5cc mineral mix
Balance fluid / 6h

Follow up on April 30th Mei 2nd

S : shortness of breath (+), fever (+), cough (+), pale (+)
O: Sens: CM, Temp: 37-37.6. BW : 28 kg.
Head

Eyes: light reflex: (+/+), pupils were isochoric, pale of

conjunctiva palpebra inferior (+/+) Ear/nose/mouth: normal in

Neck

appearance.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiform, epigastrial retraction (+)

HR: 108 bpm, regular, murmur (-) soft heart sound (+)

Abdomen

RR: 60 rpm, regular, rales (-/-)

Soft , peristaltic (+) normal, liver: palpable at 2cm BAC spleen:

Extremities

not palpable
Pulse 108 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat

(+)
A : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition.
P:

Total bed rest

Posisi Semi fowler
O2 1-2 l/i nasal canule
IVFD D5% 4gtt/micro
Inj.Lasix 30mg/12jam/IV
Propanolol 3 x 20 mg
Aldactone 2 x 12.5 mg
Digoxin 2 x 0.14 mg
Multivitamin tanpa Fe
Vitamin A
Lacfolac syrup
Diet F75 250cc/3h + 5cc mineral mix
Balance fluid / 6h

Follow up on Mei 2nd Mei 6th

S : shortness of breath (+), fever (-), cough (+), pale (+)

O: Sens: CM, Temp: 37-37.1 BW : 28 kg.

Head

Eyes: light reflex: (+/+), pupils were isochoric, pale of

conjunctiva palpebra inferior (+/+) Ear/nose/mouth: normal in

Neck

appearance.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiform, epigastrial retraction (+)

HR: 104 bpm, regular, murmur (-) soft heart sound (+)

Abdomen

RR: 62 rpm, regular, rales (-/-)

Soft, peristaltic (+) normal, liver and spleen: not palpable

Extremities

Pulse 108 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat

(+)
A : : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition.
P:

Total bed rest

Posisi Semi fowler
O2 1-2 l/i nasal canule
IVFD D5% 4gtt/micro
Inj.Lasix 30mg/12jam/IV
Propanolol 3 x 20 mg
Aldactone 2 x 12.5 mg
Digoxin 2 x 0.14 mg
Multivitamin tanpa Fe
Folic Acid
Lacfolac syrup
Diet F75 250cc/3h + 5cc mineral mix
Balance cairan / 6h

Follow up on Mei 7th Mei 10th

S : shortness of breath (+), fever (-), cough (+), pale (+)

O: Sens: CM, Temp: 36.5-37.5 BW : 28 kg.

Head

Eyes: light reflex: (+/+), pupils were isochoric, pale of

conjunctiva palpebra inferior (-/-) Ear/nose/mouth: normal in

Neck

appearance.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiform, epigastrial retraction (+)

HR: 100 bpm, regular, murmur (-) distant heart sound (+)

Abdomen

RR: 34rpm, regular, rales (-/-)

Soepel, peristaltic (+) normal, liver and spleen: not palpable

Extremities

Pulse 100 bpm, regular, p/v was adequate, warm extremities, CRT
<3
BP: 90/70 mmHG hypotropy muscle (+), loss of subcutaneous fat

(+)
A : : CHF ec dilated cardiomyopathy + moderate MR+ mild TR + minimal PE +
severe malnutrition..
P:

Total bed rest

Semi fowler position
O2 1-2 l/i nasal canule
IVFD D5% 4gtt/micro
Inj.Lasix 30mg/12jam/IV
Propanolol 3 x 20 mg
Aldactone 2 x 12.5 mg
Digoxin 2 x 0.14 mg
Cotrimoxazole 2 x 480mg
Multivitamin without Fe
Folic Acid
Lacfolac syrup
Diet F100 200cc/3h + 4cc mineral mix
Balance fluid / 6h

DISCUSSION
This case reported a 14 years old girl with dilated cardiomyopathy diagnosed based
on clinical features, chest x-ray and echocardiography. Dilated cardiomyopathy (DCM) is
diagnosed when the heart enlarged (dilated) and the pumping chambers contract poorly
(usually left side worse than right). This condition is the most common form of the
cardiomyopathy and accounts for approximately 55-60% of all childhood cardiomyopathies.

According to the pediatric cardiomyopathy registry database, this form of myopathy is

detected in roughly one per 200,000 children with roughly one new case per 160,000 children
reported each year in the United States. It can have both genetic and infectious/environmental
causes.3
Dilated cardiomyopathy can appear along a spectrum of no symptoms, subtle
symptoms or, in the more severe cases, congestive heart failure (CHF), which occurs when
the heart is unable to pump blood well enough to meet the body tissue needs for oxygen and
nutrients. When only subtle symptoms exist, infants and young children are sometimes
diagnosed with a viral upper respiratory tract infection or recurrent pneumonia without
realizing that a heart problem is the basis for these symptoms. Older children and adolescents
are less likely to be diagnosed with viral syndromes and more likely to present with
decreased exercise capacity or easy fatigability.4
With CHF, babies and young children will usually have more noticeable clinical
changes such as irritability, failure to thrive (poor gain weight), increased sweating especially
with activities, pale color, faster breathing and/or wheezing. In older children, congestive
heart failure can manifest as difficulty breathing and/or coughing, pale color, decreased urine
output and swelling, excessive sweating, and tired with minimal activities. Until the diagnosis
is made in many children, chronic coughing and wheezing, particularly during activities, can
be misinterpreted as asthma. Some patients with DCM caused by viral myocarditis
(weakened, enlarged heart muscle usually due to a viral infection) can have a rapid increase
in the number and severity of CHF symptoms such that within 2448 hours the child can
become very ill requiring emergency hospitalization, and occasionally, advanced life
support.4 In this case,this patient present with pale color, faster breathing, easily tired with
minimal activities and persistent coughing.
Once there is clinical suspicion based on the patient history and physical exam, the
diagnosis of DCM is primarily based on echocardiography. With this test, the physician will
be using ultrasound beams to evaluate the heart looking for dilated chambers and decreased
pump function. Along with the echocardiogram, there are other tests that will likely be done
to confirm the diagnosis or provide clues as to the cause. 3In this case, there is chamber
enlargement , moderate MR, mild TR and minimal pulmonary embolus found during
echocardiography.

A chest X-ray will show the heart size and can be used as a reference to follow
increases in heart size that may occur over time. In this case, her chest X-ray shows there is
an increase in heart size and proven to be cardiomegaly.
The majority of children with DCM have signs and symptoms of heart failure. The
most common types of medications used to treat heart failure include diuretics, inotropic
agents, afterload reducing agents and beta-blockers. Diuretics, sometimes called water
pills, reduce excess fluid in the lungs or other organs by increasing urine production. The
loss of excess fluid reduces the workload of the heart, reduces swelling and helps children
breathe more easily. Diuretics can be given either orally or intravenously. Common diuretics
include furosemide, spironolactone, bumetanide and metolazone. Common side effects of
diuretics include dehydration and abnormalities in the blood chemistries (particularly
potassium loss). Patient in this case has been given with lasix injection with dosage 30mg for
12 hours through intravenous.
Inotropic Agents are used to help the heart contract more effectively. Inotropic
medications and are most commonly used intravenously to support children who have severe
heart failure and are not stable enough to be home. Common types of inotropic medications
include:3

Digoxin (taken by mouth): improves the contraction of the heart. Side effects include

low heart rate, and, with high blood levels, vomiting and abnormal heart rhythm.
Dobutamine, dopamine, epinephrine, norepinephrine (intravenous medications given
in the hospital): medications that increase blood pressure and the strength of heart
contractions. Side effects include increased heart rate, arrhythmias and for some,

constriction of the arteries.

Vasopressin (intravenous medication): increases blood pressure and improves blood
flow to the kidneys. Side effect include excessive constriction of the arteries and low

sodium.
Milrinone (intravenous medication): improves heart contraction and decreases the
work of the heart by relaxing the arteries. Side effects include low blood pressure,
arrhythmias and headaches.

In this case, the patient have been treated with digoxin to improvethe contraction of her
heart.

Beta-blockers slow the heartbeat and reduce the work needed for contraction of the
heart muscle. Slowing down the heart rate can help to keep a weakened heart from
overworking. In this case, the patient had been given with propranolol. Side effects include
dizziness, low heart rate, low blood pressure, and, in some cases, fluid retention, fatigue,
impaired school performance and depression.3
Nutritional status in this patient based on the CDC curve for girls 2 20 years is
severe malnutrition, so this patient should be managed to improve his nutritional state. The
calories target for this patient, female, 14 years with body weight 28kg, body height 146 cm,
and height age 11 years is 1660 (RDA based on height age X ideal body weight). This patient
has managed by giving F75 250cc per 3 hours and 5cc of mineral mix.
Although some cases of dilated cardiomyopathy reverse with treatment of the
underlying disease, many progress inexorably to heart failure. With continued
decompensation, heart transplantation may be necessary.The prognosis for patients with heart
failure depends on several factors, with the etiology of disease being the primary factor. Other
factors play important roles in determining prognosis; for example, higher mortality rates are
associated with increased age, male sex, and severe CHF. Prognostic indices include the New
York Heart Association functional classification.The Framingham Heart Study found that
approximately 50% of patients diagnosed with CHF died within 5 years. [5] Patients with
severe heart failure have more than a 50% yearly mortality rate. Patients with mild heart
failure have significantly better prognoses, especially with optimal medical therapy. In the
this case, the patient have a poor prognosis.
SUMMARY
This paper reports about a 14 years old female diagnosed with dilated
cardiomyopathy. Diagnosis is made by clinical features, chest X-ray and echocardiography.
This patient is treated with furosemide, beta blockers and inotropic agents. Since dilated
cardiomyopathy can be chronic diseases, it is important for this patients to have good general
health practices to improve her quality of life, these include eating a well-balanced, nutritious
diet to restore and maintain muscle strength and endurance.
REFERENCE

1.

http://www.childrenscardiomyopathy.org/site/description.php [Accessed on 6th Mei

2.

2014]
https://www.bcm.edu/departments/pediatrics/cardiology/dilatedcardiomyopathy

3.

[Accessed on 6th Mei 2014]

Lilly, Leonard S., Pathophysiology of Heart Disease. Wolters Kluwer. Lippincott

4.

Williams & Wilikins. 4 edition. 2007. Page 252-258

www.mayoclinic.org/diseaseconditions/dilated.cardiomyopathy/basics/riskfactors/con-2003288 [Accessed on 7th

5.

Mei 2014]
http://emedicine.medscape.com/article/984358-medication#3 [Accessed on 5th Mei

6.

2014]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2064944/ [Accessed on 3rd Mei 2014]