A Case Of Dengue Fever with Myocarditis
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A Case Of Dengue Fever with Myocarditis

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A Case Of Dengue Fever with Myocarditis A Case Of Dengue Fever with Myocarditis Presentation Transcript

  • Dr. Prasanth Sankar Prof.Dr. E. Dhandapani’s unit
    • Mirosh D.O.A – 6/12/09
    • 18/M
    • Construction Worker
    • Orissa/Chennai
      • C/O
        • Fever
        • Headache 5 days
        • Generalized body ache
    • Abrupt onset high grade fever
    • Assoc with chills
    • Headache & retro orbital pain
    • Generalised bodyache
    • Nausea and 1-2 episodes of vomiting
    • Easy Fatiguability
    • Temp ↓paracetamol but recurred.
    • No h/o
      • Polyarthralgia
      • Rash
      • Abdominal pain/swelling
      • Hematemesis/melena/Mucosal bleeds
      • Yellowish discoloration of mucosa & skin
      • Altered consciousness/Seizures
      • Hematuria/oliguria
      • Chest pain/palpitations/breathlessness
      • Cough with expectoration
    • Past History
      • Not contributory
    • Personal History
      • not smoker/ alcoholic
      • Pan chewing +
    • Occupation
      • Construction worker
    • Family History
      • Not contributory
    • Conscious, oriented, co-operative
    • Moderate built & nourishment
    • Tachypneic, Not dyspneic
    • Conjunctival suffusion +
    • Not icteric/cyanosed
    • No pedal edema
    • No lymphadenopathy
    • No skin rash/petechiae/ecchymosis
    • No swelling or redness of joints
    • BP – 100/70 mmhg RUL in supine
    • Pulse – 54/min, regular
    • RR – 28/min
    • Temp – 102 0 F
    • CVS
      • JVP not raised
      • S1, S2+
      • No additional sounds
      • No murmurs
    • RS
      • Tachypneic
      • NVBS +
      • No added sounds
    • Abd
      • Non tender
      • No organomegaly/free fluid
      • BS +
    • CNS
      • No FND
    • PROVISIONAL DIAGNOSIS
      • A/C FEBRILE ILLNESS
      • ? DENGUE FEVER
    • 6/12/09 – done outside
      • Hb – 13.6
      • TC – 3500
      • DC – P-55/L-42/E-3
      • ESR – 5/8
      • Platelet – 80,000
      • RBS – 97
      • Urea – 27
      • Creatinine – 0.7
      • Sodium – 136
      • Potassium – 3.6
      • Smear for MP – negative
      • Widal - Negative
    • 6/12/09 – GSH
      • Hb – 13.6
      • TC – 3600
      • DC – P-45/L-52/E-3
      • PCV – 39
      • ESR – 3/7
      • Platelet – 70,000
      • RBS – 94
      • Urea – 21
      • Creatinine – 0.8
      • Sodium – 139
      • Potassium – 3.8
  •  
  •  
    • Treatment
      • Temp/BP/I-O chart
      • IV fluids
      • Tab paracetamol
      • Tab Chloroquine
      • Cap Doxycycline
      • Tab Ranitidine
      • Tab Domperidone
    • C/O fever during night
    • O/E
      • Conscious, Oriented
      • Hydration adequate
      • BP – 94/70 mm hg
      • Pulse – 58/min
      • Temp – 100.4 0 F
      • CVS/RS/Abd/CNS - WNL
  •  
  •  
    • Mild Global Hypokinesia of LV
    • Dimensions –5.0 X 3.4
    • EF – 48 %
    • Mild LV systolic Dysfunction
    • ADVICE
      • To reassess LV function after 1 week
      • Cardiac Enzymes
      • Review with results
    • USG abdomen
      • Normal 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) females
    • CK –MB –
      • 152 ng /mL (0.0 – 5.5 ng /mL)
    • Trop I –
      • 0.13 ( 0.0 – 0.08 ng/mL)
    • CBC on 10- 12-09
      • Hb – 13.0
      • TC – 7200
      • DC – P-60/L-37/E-3
      • ESR – 6/10
      • Platelet – 1,20,000
      • RBS – 117
      • Urea – 30
      • Creatinine – 0.8
    • LFT
      • T.bilirubin – 1.0
      • D. Bilirubin – 0.3
      • ALT – 66
      • AST – 74
      • ALP – 90
      • T. Protein – 6.2
      • S. Albumin – 4.3
  •  
    • Repeat Echo - 15-12-09
      • EF – 68 %
      • Dimensions - 4.4 X 3.6
      • NO RWMA.
      • Normal LV systolic function
    • ECG – 16 -12-09
      • Sinus Rhythm
      • Rate – 80/min
      • QRS – 70 0
  • 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 FEVER
    • DENGUE MYOCARDITIS WITH SINUS NODE DYSFUNCTION
  •  
    • Probable
    • acute febrile illness of 2-7 days duration (sometimes with two peaks) with two or more of the following manifestations:
      • Headache
      • Retro -orbital pain
      • Myalgia/ arthralgia
      • Rash
      • Haemorrhagic manifestation and,
      • Leukopenia.
    • And supportive serology
      • Reciprocal HAI titre >1280,
      • Comparable IgG Elisa titer, or
      • Positive 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 criteria
    • Reportable – Any probable or confirmed case should be reported
    • Lab criteria for confirming Dengue fever
      • Isolation of dengue virus from serum or autopsy samples
      • 4fold or greater change in reciprocal IgG or IgM antibody titres in paired serum samples
      • Demonstration of dengue virus antigen in autopsy tissue, serum or CSF samples by IHC, IF or ELISA
      • Detection of genomic sequences in autopsy tissue, serum, or CSF by PCR
    • Probable case of dengue fever
    • Haemorrhagic tendency evidenced by 1 or more of the following:
      • Positive tourniquet test
      • Petechiae, ecchymosis or purpura
      • Bleeding from mucosa (mostly epistaxis or bleeding from gums), injection sites or other sites
      • Haematemesis 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 sex
      • A >20% drop in haemotocrit following treatment with fluids as compared to baseline
      • Signs of plasma leakage (pleural effusion, ascites or hypoproteinaemia).
    • All the above criteria of DHF
    • Signs of circulatory failure manifested by
      • rapid and weak pulse
      • narrow 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 Review
      • Viroj Wiwanitkit Acta Cardiol Sin 2008;24:226
    • The cardiac complications in dengue are not common.
    • Myocarditis- most common documented cardiac pathology in dengue
    • However, 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 or
      • it 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 HEALTH
    • Vol 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 pathogenesis
    • ECG 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 patients
      • LV dilation in 21% (13/61) of patients.
      • Duel chamber dilatation in 16% (10/61) of patients
      • Isolated 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.
    • Conclusion
    • Dengue myocarditis was exclusively asymptomatic with no long-term sequelae.
    • Two-dimensional echocardiography was the only reliable tool of investigation
    • Sinus bradycardia was the most conspicuous ECG finding
    • Right 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 2006
    • SAM Kularatne, Senior Lecturer in Medicine, Department of Medicine, Faculty of Medicine, University of Peradeniya
    • Myocarditis 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 Lanka
    • WHO - Dengue Bulletin – Volume 30, 2006
    • S.A.M. Kularatnea*, S.L. Seneviratneb*, G.N. Malavigec*, et.al..
    • 120/174 serologically confirmed Dengue Fever Cases
    • 75 (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):e69-71
    • Lee 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 DHF
    • Sharma Aarti, Gupta Vishal, Das Umesh Dr R M L Hospital New Delhi
    • APICON 2010
    • A retrospective study done on 28 patients with DHF
    • None had clinical features of overt myocarditis
    • 5 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-T
    • 2patients (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
  •