Tropical cardiology
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This document presents a case of a 41-year-old Kenyan male presenting with wheezing, cough, and orthopnea. On exam, he has elevated blood pressure, wheezing, increased jugular venous pressure, and an abnormal EKG. The document then reviews various tropical cardiac diseases including protein-calorie malnutrition, beriberi heart disease, idiopathic cardiomyopathy, tropical endomyocardial fibrosis, pericardial diseases, rheumatic fever, and various infectious myocardiopathic diseases that can present in tropical regions.
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Tropical cardiology
- 1. Hx ●41 y/o Kenyan Male with 3d hx/o wheezing, low intensity cough and marked orthopnea ●(-) hx/o asthma ●(-) hx/o valvular heart disease ●ETOH 4 beers/wk ●(-) hx/o parasitic infection, fever, or jxt aches/skin rashes
- 2. Physical Exam ●B/P 150/104 P 64 RR 20 ●mild wheezing diffusely ●Nml PMI ●Incr JVD (5 cm@45°), nml carotid pulse ●Soft s2, nml physiologically split ●(+) s4
- 3. EKG ●NSR ●LVH with QRS widening and ST segment strain ●Abnormal EKG- No comparison EKG available
- 4. Tropical Cardiology Frank Meissner, MD, FACP, FACC, FCCP
- 6. Protein-Calorie Malnultrition ●Vacuolar degeneration of myofibrils ●Esp in conducting tissue ●Sudden death common, possibly from arrythmia ●During recovery findings of CHF often seen ●Malnourished children sensitive to digoxin, use diuretic only
- 7. Beriberi Heart Disease ●Thiamine deficiency 2° ingesting highly milled rice as staple food ●Also occurs in chronic alcoholism ●Peripheral vasodilatation - high output state ●Reduced renal blood flow with retention of Na+ & water ●Increased blood volume & biventricular failure
- 8. Beriberi - diagnostic criteria ●Hx/O Thiamine Deficiency ●Exclusion of other causes of heart disease ●High output failure ●Evidence of peripheral neuritis or pellagra ●Rapid response to therapeutic trial of Thiamine
- 9. Beriberi- treatment ●Thiamine hydrochloride 100 mg IV QD X 5 days ●Oral thiamine 50 mg qd X 1-2 weeks ●Bed rest ●± diuretics
- 11. Idiopathic Congestive Cardiomyopathy- Epidemiology ●Worldwide distribution ●High prevalence rates among blacks in tropical/subtropical Africa ●Nigeria - 30-40% CV disease 2° idiopathic cardiomyopathy
- 12. Idiopathic Congestive Cardiomyopathy- Epidemiology ●Nigeria - 2nd most common cause of cardiac death after RVD ●Southern Africa - 60% ●Postmortem study of East Africans - most common fatal heart disease
- 13. Idiopathic Congestive Cardiomyopathy- Etiology ●Multifactorial disease - ETOH, HTN, Malnutrition, viral myocarditis ●West African study 40% had chronic ETOH use + malnutrition ●Grp B Coxsackieviruses implicated if febrile illness concurrent with CHF
- 14. Idiopathic Congestive Cardiomyopathy- Pathology ●Low output failure ●Heart grossly enlarged - 500-600 gms ●Trabeculae carneae are smoothed out ●Thrombus often seen in apical region ●Mitral/tricuspid rings dilated without evidence of intrinsic valvular disease ●Often present with 1° or more often 2° HTN
- 15. Idiopathic Congestive Cardiomyopathy- Clinical Findings ●Fatigue ●Dyspnea ●Cardiomegaly ●Diffuse Cardiac Impulse ●Gallop Rhythm ●Murmurs of MR/TR
- 16. Tropical Endomyocardial Fibrosis- Epidemiology ●Uganda, Kenya, Zambia (E. Africa); Nigeria, Ghana, Ivory Coast (W. Africa) ●Brazil, Columbia, Venezuela, Mexico (S. & Cntrl America) ●Kerala & Haryana (India)
- 17. Tropical Endomyocardial Fibrosis- Epidemiology ●In Uganda - as common a cause of cardiac failure as RHD ●Uganda - seen in 25% of cardiac necropsies ●More common in poorer socioeconomic conditions ●In endemic areas 50% occur in persons < 15 yrs of age
- 18. Tropical Endomyocardial Fibrosis- Etiology ●Tropical environment ●Familial occurrence ●Circulating autoimmune heart antibodies ●Deposition of immune complexes in heart ●Elevated malaria antibody titers ●Tropical spleenomegaly
- 19. Tropical Endomyocardial Fibrosis- Pathology ●Fibrosis of mural endocardium ●Thrombus deposition followed by fibrotic organization ●Early in disease embolization may occur ●Usual extends to the mitral and tricuspid valve apparatus
- 20. Tropical Endomyocardial Fibrosis- Pathology ●Valvular regurgitation can often occur ●Restriction of cardiac filling/cardiac output ●R-ventricle infundibulum hypertrophied and dilated ●Severe R-sided failure symptoms can be seen (ascites/hepatomegaly) ●L-ventricular involvement results in MR & PAH
- 21. Tropical Endomyocardial Fibrosis- Clinical Findings ●May manifest in first several months in life ●Usually recognized in advanced stages ●Symptoms advance rapidly ●Process is usually biventricular ●High venous pressure causes exopthalmos, periorbital facial edema, jaundice
- 22. Tropical Endomyocardial Fibrosis- Clinical Findings ●Ascites almost always seen, but peripheral edema rare ●Pericarditis present approx 40% cases - aggravates restrictive cardiomyopathy ●Peripheral cyanosis and clubbing common 2° low cardiac output ●Cachexia, protein-losing enteropathy, cardiac cirrhosis with hepatic failure - terminal events
- 23. Tropical Endomyocardial Fibrosis- Clinical Findings ●Hyperdynamic RV outflow - L upper parasternum ●Murmur of TR + R-sided S3 ●Early peaking systolic MR murmur ●Late opening snap (MV) + L-sided S3 often heard ●Early peaking systolic MR murmur + opening snap unique to LV endomyocardial fibrosis
- 25. Acute Pericarditis ●Fibrinous ○Friction rub in acute rheumatic pericarditis ○Viral pericarditis - grp B coxsackie virus ●Serous ○Childhood/adult pericardial TB ○Endemic areas for endomyocardial fibrosis, childhood effusion implys this Dx
- 26. Acute Pericarditis ●Suppurative ○ Common in tropics - most commonly S. pneumoniae 2° pneumonia or S. aureus 2° osteo ○ Syndrome of cough + dyspnea + toxemia + friction rub + increasing heart size ○ Mortality > 35% even with prompt Dx/Rx ●Amebic Pericarditis ○Rare complication of liver abscess ○Rupture into pericardial sac ○“Anchovy paste” pus
- 27. Rheumatic Fever
- 28. Rheumatic Fever - Epidemiology ●0.05% of Strep infections lead to RF in developed world ●0.3 - 3% Strep infections lead to RF in third world
- 29. Rheumatic Fever- Etiology ●Nonsuppurative immunologic complication of ß-hemolytic Strep ●Only URI give rise to RF, unlike, GN 2° skin or URI infections
- 30. Rheumatic Fever- Pathology ●Endocardium, myocardium, pericardium, synovial joint linings, lungs, or pleura ●Characteristiclesion is perivascular granulomatous reaction/vasculitis ●MV involved 75-80% cases ●AoV involved 30% ●TV &/or PV < 5% cases ●Healing complete or progressive valvular disease over years and decades
- 31. Rheumatic Fever- Clinical Findings ●1-4 wks post URI ●Revised Jones Criteria - 2 major or 1 major & 2 minor criteria
- 33. Carditis ●Cardiac enlargement ●Pericardial friction rub ●Mitral or aortic vavlvular diastolic murmurs ●Prolonged PR interval ●Changing quality of heart sounds ●Tachycardia out of proportion to fever
- 34. Minor ●Hx/o previous RF or RVD ●Fever ●Polyarthralgia ●Nonspecific evidence of inflammation (increased sed rate, leukocytosis) ●Prolonged P-R interval ●Evidence of antecedent ß-hemolytic strp infection, i.e., increased ASO, recent scarlet fever
- 35. Rheumatic Fever- Treatment ●Bed rest ●ASA ●Rheumatic Fever- Prognosis
- 42. Protozoal ●Chagas Disease ●African Sleeping Sickness ●Toxoplasmosis ●Malariae ●Leishmaniasis ●Balantidiasis ●Sarcosporidosis ●Amebiasis
- 45. HIV - A completely Seperate Lecture!!!!!!