Suburban Community Hospital Blue Bell, Pennsylvania
Introduction: Pediatric third-degree atrioventricular (AV) block is a rare but potentially lethal condition with variable manifestations. We present a case of a 12-month-old female with no past medical history presenting to the office with two days of congestion and fussiness. Through a physical examination exhibiting bradycardia while crying and murmur, patient was sent to the ED for EKG and subsequently found to have a third-degree AV block. This case provides a situation in which a third-degree heart block is managed with observation rather than the traditional pacemaker placement.
Case Study: Patient presented to office with mother for two days of congestion and fussiness without fevers, waking up at night, or decreased oral intake. No sick contacts were noted at home or day care. Pertinent physical examination findings included a grade 2 diastolic cardiac murmur at left midclavicular sternal border and bradycardia with heart rate of 60 while patient was actively crying. It was determined in the setting of bradycardia and her murmur to send her to a pediatric ED for EKG evaluation. EKG findings showed third-degree atrioventricular block. Patient was subsequently admitted for evaluation. Echocardiogram returned without abnormal findings. Lyme serology was negative. Maternal lupus was tested and negative. Family denied any history of sudden cardiac death, SIDS, congenital heart disease, pacemakers, ICDs. Immunizations are up to date. As patient was asymptomatic, patient was discharged with a Holter Monitor and managed presently with observation. The cause of patient’s present third-degree AV block is unclear. In setting of patient’s sufficient heart rate following hospitalization and risks associated with pacemaker placement in at this age group, re-evaluation and decision of pacemaker treatment are to be discussed at future visit in 2024.
Discussion: This case is osteopathically relevant in the setting of the body as a unit. It has been critical to investigate causes coming from intra-cardiac pathologies in addition to non-cardiac pathologies including Lyme disease and other previous conditions that may have pre-disposed for third degree-AV block. This case provides an interesting example of a condition that is conventionally treated with urgent pacemaker placement. Presently, the indications for pacing in our patient would include bradycardia associated symptoms, left ventricular dilation or dysfunction, prolongation of the QTc, or wide complex escape. This case also highlights the significance of a complete physical examination being done particularly in the pediatric population.
