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Background: Pediatric myocarditis has an annual incidence of 1 in 100,000 children and can present with a range of signs and symptoms varying from asymptomatic to fulminant disease. The rarity of the disease and lack of specific symptoms makes diagnosis challenging; consequently, myocarditis is often underdiagnosed and subsequently may be mismanaged.

Case Report: We present a case of myocarditis in a 12-year-old male initially evaluated at a small outlying Emergency Department for fever, gastrointestinal symptoms, and lower sternal chest pain. He was found to have a lactic acidosis (11.5 mmol/L) and an elevated AST, ALT, and CK, with unremarkable chest and abdominal x-rays and a negative hepatitis panel. Patient was treated for suspected viral gastroenteritis and dehydration with intravenous fluid and transferred to a pediatric hospital. Patient continued to decompensate and developed transient episodes of 3rd-degree heart block with non-diagnostic ST changes on his EKG. An echocardiogram showed an EF of 40%. Patient was diagnosed with viral myocarditis and transferred to a pediatric cardiac ICU. He was discharge home 7 days later with a normal ejection fraction.

Discussion: When a pediatric patient presents with vague viral symptoms and shock, myocarditis should remain on the differential until it can be appropriately ruled-out. Treatment includes fluid restriction, ace-inhibitor, beta-blocker, IVIG, and heparin. Careful evaluation of all clinical evidence may aid in preventing anchoring bias and ultimately lead to successful treatment.

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