V.P. is a 13-year-old female with no past medical or surgical history who presented to an outside hospital with a three-week history of fatigue, emesis, 10-pound weight loss, headache, cough, and intermittent shortness of breath. She denied fevers, respiratory symptoms, or diarrhea. Initial lab work-up showed a normal basic metabolic panel, slightly elevated total bilirubin, and mildly elevated ALT and AST. Abdominal ultrasound was negative for gallstones. She was admitted to the GI service, but began to have worsening respiratory distress with chest tightness and desaturations. ECG showed low voltages and a wide QRS complex. She was transferred to the CICU at CHOP.

On physical exam, she was tachypneic, with difficulty lying flat. Breath sounds were decreased at the bases. Patient was tachycardic with normal S1, S2, an audible S3 gallop, and no murmurs. Extremities were warm and well perfused. Abdomen was mildly tender, and obese, making it difficult to assess for hepatomegaly. Echocardiogram showed severe LV dysfunction, SF 10 percent. Inotropic medications and diuretics were initiated. Viral blood studies were negative. The patient required CPAP for worsening respiratory distress. Due to worsening heart failure symptoms refractory to medical management, a ventricular assist device (VAD) was implanted. During implant, a core of the LV was sent for tissue PCR and pathology. V.P. stabilized on the VAD, though she was having PACs, PVCs, and intermittent atrial rhythms. Three days later, pathology on the LV core came back.

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My Diagnosis

Lisa Wray, MD, of Philadelphia submitted the correct answer to last issue’s challenge, immune thrombocytopenia, the subject of this issue’s cover article.