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TWO CASES OF MYOCARDIAL INFARCTION IN CHILDREN

Myocardial infarction in children is extremely rare and can have various etiologies. The following two case reports highlight rare but important causes of myocardial infarction in children.

Case 2: A 16-year-old boy presented with breathlessness and palpitations on minimal exertion for the past 1 month. He had no fever, respiratory symptoms or chest pain. He was a nonsmoker, nonhypertensive and non-diabetic. There was a family history of hypercholesterolemia in the younger sister. She was asymptomatic and was already on statin therapy. His younger brother died suddenly a year earlier. His parents were asymptomatic and their physical examination was normal. Unfortunately, we do not have their lipid profile.
The patient's physical examination revealed tendinous and tuberous xanthomas [Figures 3 & 4], stria palmaris and arcus juveniles. Cardiovascular examination revealed mild cardiomegaly. The electrocardiogram showed poor progression of 'R' wave in lead V1 to V4. The chest x-ray showed cardiomegaly and there was evidence of pulmonary venous hypertension. The 2-D echocardiogram showed dilated LV, with severe LV systolic dysfunction and akinetic interventricular septum, moderate mitral regurgitation and moderate pulmonary artery hypertension. His lipid profile was as follows: total cholesterol, 440 mg/dl, LDL cholesterol, 398 mg/dl, HDL cholesterol, 30 mg/dl, TG, 60 mg/dl and VLDL cholesterol, 12 mg/dl.   His coronary angiogram showed 90% discrete, osteal stenosis of the left main coronary artery and severe proximal LAD disease with mid total occlusion -[ Figure 5].  Left coronary angiogram showing left main coronary artery-osteal 90% discrete stenosis and left anterior descending-proximal 90% discrete stenosis and mid total occlusion.
He underwent coronary artery bypass grafting (CABG) on the next day uneventfully and he was discharged after 2 weeks on the following drugs: diuretics, ACE inhibitors, beta-blockers, antiplatelets (aspirin and clopidogrel) and statins (rosuvastatin and fenofibrate). He was asymptomatic during the 1 st month follow-up visit.

DISCUSSION:
Our first case suggests nephrotic syndrome as a possible cause of thrombotic occlusion of the coronary and cerebral arteries, causing MI and cerebrovascular accident in this child. Ischemic heart disease is a rare complication of nephrotic syndrome. Only few cases are reported worldwide. Silva et al. [1] reported a 7-year-old boy with a 4-year history of steroid-unresponsive nephrotic syndrome due to mesangial proliferation disease and he presented with anteroseptal MI. However, cardiac catheterization showed no evidence of atherosclerotic coronary artery disease. Thrombotic occlusion of the left anterior descending artery was the likely cause of the event, similar to our patient. Hoppet al. [2] reported a 7-year-old boy with a 5-year history of steroid-unresponsive nephrotic syndrome due to minimal change disease presenting with acute MI.
The second case had familial hypercholesterolemia. It was clinically suspected because of tendinous and tuberous xanthomas with a strong family history. The lipid profile was consistent with Frederickson's Type IIa hypercholesterolemia (homozygous). However, detailed electrophoresis or genetic workup was not available.
Accelerated atherosclerosis, spontaneous dissections and aneurysms, ectasia and anomalous origin of coronary arteries may also rarely cause MI in children.
There are no controlled trials to guide early treatment of MI in this age group. [10] In conclusion, MI in children may result from diverse causes requiring different management approaches.