A Case Of Dengue Fever with Myocarditis

Dr. Prasanth SankarProf.Dr. E. Dhandapani’s unit

Mirosh D.O.A – 6/12/0918/MConstruction WorkerOrissa/Chennai

C/OFever Headache 5 daysGeneralized body ache

Abrupt onset high grade feverAssoc with chillsHeadache & retro orbital painGeneralised bodyacheNausea and 1-2 episodes of vomitingEasy Fatiguability Temp ↓paracetamol but recurred.

No h/oPolyarthralgiaRashAbdominal pain/swellingHematemesis/melena/Mucosal bleedsYellowish discoloration of mucosa & skinAltered consciousness/SeizuresHematuria/oliguriaChest pain/palpitations/breathlessnessCough with expectoration

Past History Not contributory

Personal History not smoker/ alcoholicPan chewing +

OccupationConstruction worker

Family HistoryNot contributory

Conscious, oriented, co-operativeModerate built & nourishmentTachypneic, Not dyspneicConjunctival suffusion +Not icteric/cyanosedNo pedal edemaNo lymphadenopathyNo skin rash/petechiae/ecchymosisNo swelling or redness of joints

BP – 100/70 mmhg RUL in supinePulse – 54/min, regularRR – 28/minTemp – 1020F

CVSJVP not raisedS1, S2+No additional soundsNo murmurs

RSTachypneicNVBS +No added sounds

AbdNon tenderNo organomegaly/free fluidBS +

CNSNo FND

PROVISIONAL DIAGNOSIS

A/C FEBRILE ILLNESS? DENGUE FEVER

6/12/09 – done outsideHb – 13.6TC – 3500DC – P-55/L-42/E-3ESR – 5/8Platelet – 80,000RBS – 97Urea – 27Creatinine – 0.7Sodium – 136Potassium – 3.6Smear for MP – negativeWidal - Negative

6/12/09 – GSHHb – 13.6TC – 3600DC – P-45/L-52/E-3PCV – 39ESR – 3/7Platelet – 70,000RBS – 94Urea – 21Creatinine – 0.8Sodium – 139Potassium – 3.8

TreatmentTemp/BP/I-O chartIV fluidsTab paracetamolTab ChloroquineCap DoxycyclineTab RanitidineTab Domperidone

C/O fever during nightO/E

Conscious, OrientedHydration adequateBP – 94/70 mm hgPulse – 58/minTemp – 100.40 FCVS/RS/Abd/CNS - WNL

Mild Global Hypokinesia of LVDimensions –5.0 X 3.4EF – 48 %Mild LV systolic Dysfunction

ADVICETo reassess LV function after 1 weekCardiac EnzymesReview with results

USG abdomenNormal Study.

MSAT – negative.Widal – negative.QBC for MP – negative.P.smear for MP – negative.DENGUE IgM – POSITIVE.

CK –Total – 782 U/L (51 – 294 U/L) males

(39 – 238 U/L) femalesCK –MB –

152 ng /mL (0.0 – 5.5 ng /mL)Trop I –

0.13 ( 0.0 – 0.08 ng/mL)

CBC on 10- 12-09Hb – 13.0TC – 7200DC – P-60/L-37/E-3ESR – 6/10Platelet – 1,20,000RBS – 117Urea – 30Creatinine – 0.8

LFTT.bilirubin – 1.0D. Bilirubin – 0.3ALT – 66AST – 74ALP – 90T. Protein – 6.2S. Albumin – 4.3

Repeat Echo - 15-12-09EF – 68 %Dimensions - 4.4 X 3.6 NO RWMA.Normal LV systolic function

ECG – 16 -12-09Sinus RhythmRate – 80/minQRS – 700

Date Temp Pulse BP

8 -12-09 101 60 90/60

10-12-09 98.4 56 96/70

12 -12-09 98.6 60 100/70

14-12-09 98.4 68 100/70

16-12-09 98.4 76 110/72

DENGUE FEVERDENGUE MYOCARDITIS WITH SINUS NODE DYSFUNCTION

Probableacute febrile illness of 2-7 days duration (sometimes with two peaks) with two or more of the following manifestations:

HeadacheRetro -orbital painMyalgia/ arthralgiaRashHaemorrhagic manifestation and,Leukopenia.

And supportive serologyReciprocal HAI titre >1280,Comparable IgG Elisa titer, orPositive IgM Ab test on a late acute or convalascent serum

Or Occurrence at the same location & time as other confirmed cases

Confirmed – A case confirmed by Lab criteriaReportable – Any probable or confirmed case should be reportedLab criteria for confirming Dengue fever

Isolation of dengue virus from serum or autopsy samples4fold or greater change in reciprocal IgG or IgM antibody titres in paired serum samplesDemonstration of dengue virus antigen in autopsy tissue, serum or CSF samples by IHC, IF or ELISADetection of genomic sequences in autopsy tissue, serum, or CSF by PCR

Probable case of dengue feverHaemorrhagic tendency evidenced by 1 or more of the following:

Positive tourniquet testPetechiae, ecchymosis or purpuraBleeding from mucosa (mostly epistaxis or bleeding from gums), injection sites or other sitesHaematemesis or melena

Thrombocytopaenia (platelets 100,000/cu.mm or less)

Contd…

Evidence of plasma leakage due to increased capillary permeability manifested by one or more of the following:

A >20% rise in haemotocrit for age and sexA >20% drop in haemotocrit following treatment with fluids as compared to baselineSigns of plasma leakage (pleural effusion, ascites or hypoproteinaemia).

All the above criteria of DHFSigns of circulatory failure manifested by

rapid and weak pulsenarrow pulse pressure (< or equal to 20 mm Hg)

Hypotension for age, cold and clammy skin and restlessness.

DF/DHF has an unpredictable course. Most patients have a febrile phase lasting 2 -7 days. This is followed by a critical phase which is of about 2-3 days duration. During this phase, the patient is afebrile, and is at risk of developing DHF/DSS which may prove fatal if prompt and appropriate treatment is not provided. Since haemorrhage and or shock can occur rapidly, arrangements for rapid and appropriate treatment should be always available.

Dengue Cardiac Infection, A Brief ReviewViroj Wiwanitkit Acta Cardiol Sin 2008;24:226

The cardiac complications in dengue are not common.Myocarditis- most common documented cardiac pathology in dengueHowever, only a few cases are reported in world literature.probable reason for the low incidence of dengue myocarditis:

it might represent the rarity of the cases orit might be due to underdiagnosis and neglecting to report.

such myocarditis was very rare and might not be fatal if early diagnosed and treated

Horta Veloso et al, - cardiac rhythm disorders, such as AV blocks and VPCs, can appear during infection and are attributed to viral myocarditis.Formed immune complex in dengue infection could not be entrapped in the valvular space, therefore, dengue endocarditis could not exist.Dengue pericarditis can be seen but it is very rare and in the form of myopericarditis.Extension of dengue myocarditis into the pericardium rather than circulating immune complex.

SOUTHEAST ASIAN J TROPICAL MED & PUBLIC HEALTHVol 35 No. 3 September 2004

Myocardial dysfunction can be seen in patients with DHF. 20% of DHF have a LV ejection fraction of lessthan 50%, and are likely to return to normal within a few weeks.Alternation of autonomic tone and prolonged hypotension may play a role in the pathogenesisECG abnormalities have been reported in 44-75% of patients.PR prolongation or sinus bradycardia commonly occurs (Smyth and Powell,1954; Boon, 1967)Some have reported AV block in variable degrees (Lim et al, 1970;Kongpattanayothin et al, 2000).

Asymptomatic myocardial involvement in acute dengue virus infection in a cohort of adult Sri Lankans admitted to a tertiary referral centre

THE BRITISH JOURNAL OF CARDIOLOGY – VOLUME 14 ISSUE 3 . MAY/JUNE 2007

217 patients satisfied the minimum criteria of dengue fever, of whom 85% had undergone 2-D echo.Dengue IgM antibody was positive in 95% of patients.Evidence of 2-D echocardiographic myocarditis in 24%. Male:female ratio of 2:1, Age distribution of 12–65 y; 65% were in 12–30 y age group. None had clinical features of overt myocarditis, such as significant sinus tachycardia, raised JVP, triple rhythm, bilateral pulmonary crepitations and peripheral oedema

All had a relative bradycardia of around 50–60 beats per minute despite 2-D echo abnormalities suggestive of acute myocarditis. 1 patient had a regularly irregular pulse rate which was subsequently diagnosed to be due to Wencheback’s.No other ECG abnormalities in the myocarditis group.2-D echo showed –

RV showed dilation with associated TR in 57% (35/61) of patientsLV dilation in 21% (13/61) of patients.Duel chamber dilatation in 16% (10/61) of patientsIsolated TR in 6% of patients.

All had a satisfactory ejection fraction.

CPK-MB values were not helpful in diagnosing myocardial involvement. All myocarditis patients were found to have dengue virus infection of the D2 serotype.

ConclusionDengue myocarditis was exclusively asymptomatic with no long-term sequelae.Two-dimensional echocardiography was the only reliable tool of investigationSinus bradycardia was the most conspicuous ECG findingRight ventricular involvement dominated over left ventricular involvement

Myocarditis in three patients with dengue virus type DEN 3 infection

Ceylon Medical Journal Vol. 51, No. 2, June 2006SAM Kularatne, Senior Lecturer in Medicine, Department of Medicine, Faculty of

Medicine, University of PeradeniyaMyocarditis and cardiac dysfunction are recognised complications of dengue fever, but very few studies have identified the causative dengue virus (DEN) type. We report three cases of DEN 3 who had significant cardiac dysfunction suggestive of myocarditis in an outbreak of dengue fever in Kandy, Sri Lanka in April 2005.Blood samples were obtained within four days of the onset of fever and subjected to RT-PCR-AGE assay and Semi-nested—PCR-AGE assay. Acute sera were tested for IgM antibodies using MAC-ELISA and rapid strip test to detect high titres of both IgM and IgG.

Synopsis of Findings from Recent Studies on Dengue in Sri LankaWHO - Dengue Bulletin – Volume 30, 2006S.A.M. Kularatnea*, S.L. Seneviratneb*, G.N. Malavigec*, et.al..

120/174 serologically confirmed Dengue Fever Cases75 (62.5%) patients had cardiac involvement.PCR was done on acute blood samples of 20 patients, and, in three samples, DENV-3 was the causative serotype. None had DHF and most of those affected were hospital workers & medical students, suggesting a clustering of cases.Myocarditis as a sporadic complication of dengue fever has been previously reported.However, its emergence as a major outbreak has not yet been described. This may be related to subtle changes in the infecting viral genome. Clinicians need to look out for these newer manifestations and trends and use these findings to develop appropriate management guidelines and strategies.

Heart and Skeletal Muscle Are Targets of Dengue Virus Infection

The Pediatric Infectious Disease Journal: 21 December 2009

11 children with DHF presented with symptoms of myocarditis. Widespread viral infection of the heart, myocardial endothelium, and cardiomyocytes, accompanied by inflammation was observed in 1 fatal case.Myocytes were infected by dengue virus and had increased expression of the inflammatory genes and protein IP-10. Infected myocytes had ↑ in intracellular Ca2+ concentration- may directly contribute to the presentation of myocarditis in pediatric patients.

Fulminant dengue myocarditis masquerading as AMI.International Journal of Cardiology. 2009 Aug 21;136(3):e69-71Lee CH, Teo C, Low AF. The Heart Institute, National University Hospital

Singapore, Singapore.

A 25-yr Indian male, suffered from fulminant dengue myocarditis, presented to a our hospital with symptoms and ECG features mimicking acute MI. Patient succumbed before the dengue serology results were available.

Subclinical Cardiac Involvement in DHFSharma Aarti, Gupta Vishal, Das Umesh Dr R M L Hospital New

DelhiAPICON 2010

A retrospective study done on 28 patients with DHFNone had clinical features of overt myocarditis5 patients (17.8%) had sinus bradycardia (HR<60 bpm,) there were no other ECG abnormalities. 20 patients (71%) had significantly raised cardiac enzymes CPK-MB, LDH and SGOT.12 patients (42.8%) positive for Serum TROPONIN-T2patients (7%) had grade 1 diastolic dysfunction in 2D-ECHO and 1 patient(3.5%) had mild pericardial effusion

Cardiac involvement in dengue is not uncommon.Silent Myocarditis is the commonest manifestation.Life threatening cardiac involvement is rare.Sinus bradycardia is the commonest clinical and ECG manifestation.2D Echo is a valid tool in the diagnosis. Clinicians have to look out for these newer manifestations and develop appropriate strategies