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

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  • 1. Dr. Prasanth Sankar Prof.Dr. E. Dhandapani’s unit
  • 2. <ul><li>Mirosh D.O.A – 6/12/09 </li></ul><ul><li>18/M </li></ul><ul><li>Construction Worker </li></ul><ul><li>Orissa/Chennai </li></ul><ul><ul><li>C/O </li></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Headache 5 days </li></ul></ul></ul><ul><ul><ul><li>Generalized body ache </li></ul></ul></ul>
  • 3. <ul><li>Abrupt onset high grade fever </li></ul><ul><li>Assoc with chills </li></ul><ul><li>Headache & retro orbital pain </li></ul><ul><li>Generalised bodyache </li></ul><ul><li>Nausea and 1-2 episodes of vomiting </li></ul><ul><li>Easy Fatiguability </li></ul><ul><li>Temp ↓paracetamol but recurred. </li></ul>
  • 4. <ul><li>No h/o </li></ul><ul><ul><li>Polyarthralgia </li></ul></ul><ul><ul><li>Rash </li></ul></ul><ul><ul><li>Abdominal pain/swelling </li></ul></ul><ul><ul><li>Hematemesis/melena/Mucosal bleeds </li></ul></ul><ul><ul><li>Yellowish discoloration of mucosa & skin </li></ul></ul><ul><ul><li>Altered consciousness/Seizures </li></ul></ul><ul><ul><li>Hematuria/oliguria </li></ul></ul><ul><ul><li>Chest pain/palpitations/breathlessness </li></ul></ul><ul><ul><li>Cough with expectoration </li></ul></ul>
  • 5. <ul><li>Past History </li></ul><ul><ul><li>Not contributory </li></ul></ul><ul><li>Personal History </li></ul><ul><ul><li>not smoker/ alcoholic </li></ul></ul><ul><ul><li>Pan chewing + </li></ul></ul><ul><li>Occupation </li></ul><ul><ul><li>Construction worker </li></ul></ul><ul><li>Family History </li></ul><ul><ul><li>Not contributory </li></ul></ul>
  • 6. <ul><li>Conscious, oriented, co-operative </li></ul><ul><li>Moderate built & nourishment </li></ul><ul><li>Tachypneic, Not dyspneic </li></ul><ul><li>Conjunctival suffusion + </li></ul><ul><li>Not icteric/cyanosed </li></ul><ul><li>No pedal edema </li></ul><ul><li>No lymphadenopathy </li></ul><ul><li>No skin rash/petechiae/ecchymosis </li></ul><ul><li>No swelling or redness of joints </li></ul>
  • 7. <ul><li>BP – 100/70 mmhg RUL in supine </li></ul><ul><li>Pulse – 54/min, regular </li></ul><ul><li>RR – 28/min </li></ul><ul><li>Temp – 102 0 F </li></ul><ul><li>CVS </li></ul><ul><ul><li>JVP not raised </li></ul></ul><ul><ul><li>S1, S2+ </li></ul></ul><ul><ul><li>No additional sounds </li></ul></ul><ul><ul><li>No murmurs </li></ul></ul>
  • 8. <ul><li>RS </li></ul><ul><ul><li>Tachypneic </li></ul></ul><ul><ul><li>NVBS + </li></ul></ul><ul><ul><li>No added sounds </li></ul></ul><ul><li>Abd </li></ul><ul><ul><li>Non tender </li></ul></ul><ul><ul><li>No organomegaly/free fluid </li></ul></ul><ul><ul><li>BS + </li></ul></ul><ul><li>CNS </li></ul><ul><ul><li>No FND </li></ul></ul>
  • 9. <ul><li>PROVISIONAL DIAGNOSIS </li></ul><ul><ul><li>A/C FEBRILE ILLNESS </li></ul></ul><ul><ul><li>? DENGUE FEVER </li></ul></ul>
  • 10. <ul><li>6/12/09 – done outside </li></ul><ul><ul><li>Hb – 13.6 </li></ul></ul><ul><ul><li>TC – 3500 </li></ul></ul><ul><ul><li>DC – P-55/L-42/E-3 </li></ul></ul><ul><ul><li>ESR – 5/8 </li></ul></ul><ul><ul><li>Platelet – 80,000 </li></ul></ul><ul><ul><li>RBS – 97 </li></ul></ul><ul><ul><li>Urea – 27 </li></ul></ul><ul><ul><li>Creatinine – 0.7 </li></ul></ul><ul><ul><li>Sodium – 136 </li></ul></ul><ul><ul><li>Potassium – 3.6 </li></ul></ul><ul><ul><li>Smear for MP – negative </li></ul></ul><ul><ul><li>Widal - Negative </li></ul></ul><ul><li>6/12/09 – GSH </li></ul><ul><ul><li>Hb – 13.6 </li></ul></ul><ul><ul><li>TC – 3600 </li></ul></ul><ul><ul><li>DC – P-45/L-52/E-3 </li></ul></ul><ul><ul><li>PCV – 39 </li></ul></ul><ul><ul><li>ESR – 3/7 </li></ul></ul><ul><ul><li>Platelet – 70,000 </li></ul></ul><ul><ul><li>RBS – 94 </li></ul></ul><ul><ul><li>Urea – 21 </li></ul></ul><ul><ul><li>Creatinine – 0.8 </li></ul></ul><ul><ul><li>Sodium – 139 </li></ul></ul><ul><ul><li>Potassium – 3.8 </li></ul></ul>
  • 11.  
  • 12.  
  • 13. <ul><li>Treatment </li></ul><ul><ul><li>Temp/BP/I-O chart </li></ul></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Tab paracetamol </li></ul></ul><ul><ul><li>Tab Chloroquine </li></ul></ul><ul><ul><li>Cap Doxycycline </li></ul></ul><ul><ul><li>Tab Ranitidine </li></ul></ul><ul><ul><li>Tab Domperidone </li></ul></ul>
  • 14. <ul><li>C/O fever during night </li></ul><ul><li>O/E </li></ul><ul><ul><li>Conscious, Oriented </li></ul></ul><ul><ul><li>Hydration adequate </li></ul></ul><ul><ul><li>BP – 94/70 mm hg </li></ul></ul><ul><ul><li>Pulse – 58/min </li></ul></ul><ul><ul><li>Temp – 100.4 0 F </li></ul></ul><ul><ul><li>CVS/RS/Abd/CNS - WNL </li></ul></ul>
  • 15.  
  • 16.  
  • 17. <ul><li>Mild Global Hypokinesia of LV </li></ul><ul><li>Dimensions –5.0 X 3.4 </li></ul><ul><li>EF – 48 % </li></ul><ul><li>Mild LV systolic Dysfunction </li></ul><ul><li>ADVICE </li></ul><ul><ul><li>To reassess LV function after 1 week </li></ul></ul><ul><ul><li>Cardiac Enzymes </li></ul></ul><ul><ul><li>Review with results </li></ul></ul>
  • 18. <ul><li>USG abdomen </li></ul><ul><ul><li>Normal Study. </li></ul></ul><ul><li>MSAT – negative. </li></ul><ul><li>Widal – negative. </li></ul><ul><li>QBC for MP – negative. </li></ul><ul><li>P.smear for MP – negative. </li></ul><ul><li>DENGUE IgM – POSITIVE. </li></ul>
  • 19. <ul><li>CK –Total – </li></ul><ul><ul><li>782 U/L (51 – 294 U/L) males </li></ul></ul><ul><ul><li>(39 – 238 U/L) females </li></ul></ul><ul><li>CK –MB – </li></ul><ul><ul><li>152 ng /mL (0.0 – 5.5 ng /mL) </li></ul></ul><ul><li>Trop I – </li></ul><ul><ul><li>0.13 ( 0.0 – 0.08 ng/mL) </li></ul></ul>
  • 20. <ul><li>CBC on 10- 12-09 </li></ul><ul><ul><li>Hb – 13.0 </li></ul></ul><ul><ul><li>TC – 7200 </li></ul></ul><ul><ul><li>DC – P-60/L-37/E-3 </li></ul></ul><ul><ul><li>ESR – 6/10 </li></ul></ul><ul><ul><li>Platelet – 1,20,000 </li></ul></ul><ul><ul><li>RBS – 117 </li></ul></ul><ul><ul><li>Urea – 30 </li></ul></ul><ul><ul><li>Creatinine – 0.8 </li></ul></ul><ul><li>LFT </li></ul><ul><ul><li>T.bilirubin – 1.0 </li></ul></ul><ul><ul><li>D. Bilirubin – 0.3 </li></ul></ul><ul><ul><li>ALT – 66 </li></ul></ul><ul><ul><li>AST – 74 </li></ul></ul><ul><ul><li>ALP – 90 </li></ul></ul><ul><ul><li>T. Protein – 6.2 </li></ul></ul><ul><ul><li>S. Albumin – 4.3 </li></ul></ul>
  • 21.  
  • 22. <ul><li>Repeat Echo - 15-12-09 </li></ul><ul><ul><li>EF – 68 % </li></ul></ul><ul><ul><li>Dimensions - 4.4 X 3.6 </li></ul></ul><ul><ul><li>NO RWMA. </li></ul></ul><ul><ul><li>Normal LV systolic function </li></ul></ul><ul><li>ECG – 16 -12-09 </li></ul><ul><ul><li>Sinus Rhythm </li></ul></ul><ul><ul><li>Rate – 80/min </li></ul></ul><ul><ul><li>QRS – 70 0 </li></ul></ul>
  • 23. 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
  • 24. <ul><li>DENGUE FEVER </li></ul><ul><li>DENGUE MYOCARDITIS WITH SINUS NODE DYSFUNCTION </li></ul>
  • 25.  
  • 26. <ul><li>Probable </li></ul><ul><li>acute febrile illness of 2-7 days duration (sometimes with two peaks) with two or more of the following manifestations: </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Retro -orbital pain </li></ul></ul><ul><ul><li>Myalgia/ arthralgia </li></ul></ul><ul><ul><li>Rash </li></ul></ul><ul><ul><li>Haemorrhagic manifestation and, </li></ul></ul><ul><ul><li>Leukopenia. </li></ul></ul><ul><li>And supportive serology </li></ul><ul><ul><li>Reciprocal HAI titre >1280, </li></ul></ul><ul><ul><li>Comparable IgG Elisa titer, or </li></ul></ul><ul><ul><li>Positive IgM Ab test on a late acute or convalascent serum </li></ul></ul><ul><ul><li>Or Occurrence at the same location & time as other confirmed cases </li></ul></ul>
  • 27. <ul><li>Confirmed – A case confirmed by Lab criteria </li></ul><ul><li>Reportable – Any probable or confirmed case should be reported </li></ul><ul><li>Lab criteria for confirming Dengue fever </li></ul><ul><ul><li>Isolation of dengue virus from serum or autopsy samples </li></ul></ul><ul><ul><li>4fold or greater change in reciprocal IgG or IgM antibody titres in paired serum samples </li></ul></ul><ul><ul><li>Demonstration of dengue virus antigen in autopsy tissue, serum or CSF samples by IHC, IF or ELISA </li></ul></ul><ul><ul><li>Detection of genomic sequences in autopsy tissue, serum, or CSF by PCR </li></ul></ul>
  • 28. <ul><li>Probable case of dengue fever </li></ul><ul><li>Haemorrhagic tendency evidenced by 1 or more of the following: </li></ul><ul><ul><li>Positive tourniquet test </li></ul></ul><ul><ul><li>Petechiae, ecchymosis or purpura </li></ul></ul><ul><ul><li>Bleeding from mucosa (mostly epistaxis or bleeding from gums), injection sites or other sites </li></ul></ul><ul><ul><li>Haematemesis or melena </li></ul></ul><ul><li>Thrombocytopaenia (platelets 100,000/cu.mm or less) </li></ul><ul><li>Contd… </li></ul>
  • 29. <ul><li>Evidence of plasma leakage due to increased capillary permeability manifested by one or more of the following: </li></ul><ul><ul><li>A >20% rise in haemotocrit for age and sex </li></ul></ul><ul><ul><li>A >20% drop in haemotocrit following treatment with fluids as compared to baseline </li></ul></ul><ul><ul><li>Signs of plasma leakage (pleural effusion, ascites or hypoproteinaemia). </li></ul></ul>
  • 30. <ul><li>All the above criteria of DHF </li></ul><ul><li>Signs of circulatory failure manifested by </li></ul><ul><ul><li>rapid and weak pulse </li></ul></ul><ul><ul><li>narrow pulse pressure (< or equal to 20 mm Hg) </li></ul></ul><ul><li>Hypotension for age, cold and clammy skin and restlessness. </li></ul>
  • 31. <ul><li>DF/DHF has an unpredictable course. Most patients have a febrile phase lasting 2 -7 days. </li></ul><ul><li>This is followed by a critical phase which is of about 2-3 days duration. </li></ul><ul><li>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. </li></ul><ul><li>Since haemorrhage and or shock can occur rapidly, arrangements for rapid and appropriate treatment should be always available. </li></ul>
  • 32.  
  • 33.  
  • 34. <ul><li>Dengue Cardiac Infection, A Brief Review </li></ul><ul><ul><li>Viroj Wiwanitkit Acta Cardiol Sin 2008;24:226 </li></ul></ul><ul><li>The cardiac complications in dengue are not common. </li></ul><ul><li>Myocarditis- most common documented cardiac pathology in dengue </li></ul><ul><li>However, only a few cases are reported in world literature. </li></ul><ul><li>probable reason for the low incidence of dengue myocarditis: </li></ul><ul><ul><li>it might represent the rarity of the cases or </li></ul></ul><ul><ul><li>it might be due to underdiagnosis and neglecting to report. </li></ul></ul><ul><li>such myocarditis was very rare and might not be fatal if early diagnosed and treated </li></ul>
  • 35. <ul><li>Horta Veloso et al, - cardiac rhythm disorders, such as AV blocks and VPCs, can appear during infection and are attributed to viral myocarditis. </li></ul><ul><li>Formed immune complex in dengue infection could not be entrapped in the valvular space, therefore, dengue endocarditis could not exist. </li></ul><ul><li>Dengue pericarditis can be seen but it is very rare and in the form of myopericarditis. </li></ul><ul><li>Extension of dengue myocarditis into the pericardium rather than circulating immune complex. </li></ul>
  • 36. <ul><li>SOUTHEAST ASIAN J TROPICAL MED & PUBLIC HEALTH </li></ul><ul><li>Vol 35 No. 3 September 2004 </li></ul>
  • 37. <ul><li>Myocardial dysfunction can be seen in patients with DHF. </li></ul><ul><li>20% of DHF have a LV ejection fraction of lessthan 50%, and are likely to return to normal within a few weeks. </li></ul><ul><li>Alternation of autonomic tone and prolonged hypotension may play a role in the pathogenesis </li></ul><ul><li>ECG abnormalities have been reported in 44-75% of patients. </li></ul><ul><li>PR prolongation or sinus bradycardia commonly occurs (Smyth and Powell,1954; Boon, 1967) </li></ul><ul><li>Some have reported AV block in variable degrees (Lim et al, 1970; Kongpattanayothin et al, 2000). </li></ul>
  • 38. <ul><li>Asymptomatic myocardial involvement in acute dengue virus infection in a cohort of adult Sri Lankans admitted to a tertiary referral centre </li></ul><ul><li>THE BRITISH JOURNAL OF CARDIOLOGY – VOLUME 14 ISSUE 3 . MAY/JUNE 2007 </li></ul><ul><li>217 patients satisfied the minimum criteria of dengue fever, of whom 85% had undergone 2-D echo. </li></ul><ul><li>Dengue IgM antibody was positive in 95% of patients. </li></ul><ul><li>Evidence of 2-D echocardiographic myocarditis in 24%. </li></ul><ul><li>Male:female ratio of 2:1, </li></ul><ul><li>Age distribution of 12–65 y; 65% were in 12–30 y age group. </li></ul><ul><li>None had clinical features of overt myocarditis, such as significant sinus tachycardia, raised JVP, triple rhythm, bilateral pulmonary crepitations and peripheral oedema </li></ul>
  • 39. <ul><li>All had a relative bradycardia of around 50–60 beats per minute despite 2-D echo abnormalities suggestive of acute myocarditis. </li></ul><ul><li>1 patient had a regularly irregular pulse rate which was subsequently diagnosed to be due to Wencheback’s. </li></ul><ul><li>No other ECG abnormalities in the myocarditis group. </li></ul><ul><li>2-D echo showed – </li></ul><ul><ul><li>RV showed dilation with associated TR in 57% (35/61) of patients </li></ul></ul><ul><ul><li>LV dilation in 21% (13/61) of patients. </li></ul></ul><ul><ul><li>Duel chamber dilatation in 16% (10/61) of patients </li></ul></ul><ul><ul><li>Isolated TR in 6% of patients. </li></ul></ul><ul><li>All had a satisfactory ejection fraction. </li></ul>
  • 40. <ul><li>CPK-MB values were not helpful in diagnosing myocardial involvement. </li></ul><ul><li>All myocarditis patients were found to have dengue virus infection of the D2 serotype. </li></ul><ul><li>Conclusion </li></ul><ul><li>Dengue myocarditis was exclusively asymptomatic with no long-term sequelae. </li></ul><ul><li>Two-dimensional echocardiography was the only reliable tool of investigation </li></ul><ul><li>Sinus bradycardia was the most conspicuous ECG finding </li></ul><ul><li>Right ventricular involvement dominated over left ventricular involvement </li></ul>
  • 41. <ul><li>Myocarditis in three patients with dengue virus type DEN 3 infection </li></ul><ul><li>Ceylon Medical Journal Vol. 51, No. 2, June 2006 </li></ul><ul><li>SAM Kularatne, Senior Lecturer in Medicine, Department of Medicine, Faculty of Medicine, University of Peradeniya </li></ul><ul><li>Myocarditis and cardiac dysfunction are recognised complications of dengue fever, but very few studies have identified the causative dengue virus (DEN) type. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Acute sera were tested for IgM antibodies using MAC-ELISA and rapid strip test to detect high titres of both IgM and IgG. </li></ul>
  • 42. <ul><li>Synopsis of Findings from Recent Studies on Dengue in Sri Lanka </li></ul><ul><li>WHO - Dengue Bulletin – Volume 30, 2006 </li></ul><ul><li>S.A.M. Kularatnea*, S.L. Seneviratneb*, G.N. Malavigec*, et.al.. </li></ul><ul><li>120/174 serologically confirmed Dengue Fever Cases </li></ul><ul><li>75 (62.5%) patients had cardiac involvement. </li></ul><ul><li>PCR was done on acute blood samples of 20 patients, and, in three samples, DENV-3 was the causative serotype. </li></ul><ul><li>None had DHF and most of those affected were hospital workers & medical students, suggesting a clustering of cases. </li></ul><ul><li>Myocarditis as a sporadic complication of dengue fever has been previously reported. </li></ul><ul><li>However, its emergence as a major outbreak has not yet been described. This may be related to subtle changes in the infecting viral genome. </li></ul><ul><li>Clinicians need to look out for these newer manifestations and trends and use these findings to develop appropriate management guidelines and strategies . </li></ul>
  • 43. <ul><li>Heart and Skeletal Muscle Are Targets of Dengue Virus Infection </li></ul><ul><li>The Pediatric Infectious Disease Journal: 21 December 2009 </li></ul><ul><li>11 children with DHF presented with symptoms of myocarditis. </li></ul><ul><li>Widespread viral infection of the heart, myocardial endothelium, and cardiomyocytes, accompanied by inflammation was observed in 1 fatal case. </li></ul><ul><li>Myocytes were infected by dengue virus and had increased expression of the inflammatory genes and protein IP-10. </li></ul><ul><li>Infected myocytes had ↑ in intracellular Ca2+ concentration- may directly contribute to the presentation of myocarditis in pediatric patients. </li></ul>
  • 44. <ul><li>Fulminant dengue myocarditis masquerading as AMI. </li></ul><ul><li>International Journal of Cardiology. 2009 Aug 21;136(3):e69-71 </li></ul><ul><li>Lee CH, Teo C, Low AF. The Heart Institute, National University Hospital Singapore, Singapore. </li></ul><ul><li>A 25-yr Indian male, suffered from fulminant dengue myocarditis, presented to a our hospital with symptoms and ECG features mimicking acute MI. </li></ul><ul><li>Patient succumbed before the dengue serology results were available. </li></ul>
  • 45. <ul><li>Subclinical Cardiac Involvement in DHF </li></ul><ul><li>Sharma Aarti, Gupta Vishal, Das Umesh Dr R M L Hospital New Delhi </li></ul><ul><li>APICON 2010 </li></ul><ul><li>A retrospective study done on 28 patients with DHF </li></ul><ul><li>None had clinical features of overt myocarditis </li></ul><ul><li>5 patients (17.8%) had sinus bradycardia (HR<60 bpm,) there were no other ECG abnormalities. </li></ul><ul><li>20 patients (71%) had significantly raised cardiac enzymes CPK-MB, LDH and SGOT. </li></ul><ul><li>12 patients (42.8%) positive for Serum TROPONIN-T </li></ul><ul><li>2patients (7%) had grade 1 diastolic dysfunction in 2D-ECHO and 1 patient(3.5%) had mild pericardial effusion </li></ul>
  • 46. <ul><li>Cardiac involvement in dengue is not uncommon. </li></ul><ul><li>Silent Myocarditis is the commonest manifestation. </li></ul><ul><li>Life threatening cardiac involvement is rare. </li></ul><ul><li>Sinus bradycardia is the commonest clinical and ECG manifestation. </li></ul><ul><li>2D Echo is a valid tool in the diagnosis. </li></ul><ul><li>Clinicians have to look out for these newer manifestations and develop appropriate strategies </li></ul>
  • 47.  

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