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A Case Of Dengue Fever with Myocarditis
 

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
    •