Tropical Cardiology

US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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

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

EKG
• NSR
• LVH with QRS widening and ST segment
strain
• Abnormal EKG- No comparison EKG
available

Tropical Cardiology
Frank Meissner, MD, FACP, FACC, FCCP

Nutritional Cardiac Diseases

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

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

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

Beriberi- treatment
• Thiamine hydrochloride 100 mg IV QD X 5
days
• Oral thiamine 50 mg qd X 1-2 weeks
• Bed rest
• ± diuretics

Non-infectious
Myocardiopathic Diseases

Idiopathic Congestive
Cardiomyopathy- Epidemiology
• Worldwide distribution
• High prevalence rates among blacks in
tropical/subtropical Africa
• Nigeria - 30-40% CV disease 2° idiopathic
cardiomyopathy

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

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

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

Cardiomyopathy-
Clinical Findings• Fatigue
• Dyspnea
• Cardiomegaly
• Diffuse Cardiac Impulse
• Gallop Rhythm
• Murmurs of MR/TR

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)

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

Fibrosis- Etiology
• Tropical environment
• Familial occurrence
• Circulating autoimmune heart antibodies
• Deposition of immune complexes in heart
• Elevated malaria antibody titers
• Tropical spleenomegaly

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

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

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

• 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

• 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

Pericardial Disease

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

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

Rheumatic Fever

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

Rheumatic Fever- Etiology
• Nonsuppurative immunologic complication
of ß-hemolytic Strep
• Only URI give rise to RF, unlike, GN 2°
skin or URI infections

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

Rheumatic Fever-
Clinical Findings
• 1-4 wks post URI
• Revised Jones Criteria - 2 major or 1 major
& 2 minor criteria

Major
• Carditis
• Polyarthritis
• Syndenham’s chorea
• Erythema marginatum
• Subcutaneous nodules

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

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

Rheumatic Fever-
Treatment
• Bed rest
• ASA
• Rheumatic Fever- Prognosis

Infectious
Myocardiopathic
Diseases

Bacterial
• Diphtheria
• Tuberculosis
• Typhoid Fever
• Psittacosis
• Brucellosis
• Chylamdia trachomatis
• Actinomycosis

Bacterial
• Tetanus
• Tularemia
• Meliodosis
• Legionaires Disease
• Mycoplasma

Spirochetal
• Syphilis
• Leptospirosis
• Relapsing Fever
• Lyme Disease

Rickettsial
• Typhus
• RMSF
• Q Fever

Mycotic
• Blastomycosis
• Candidiasis
• Aspergillosis
• Histoplasmosis
• Sporotrichosis
• Coccidoidomycosis
• Cryptococcosis
• Mucormycosis

Protozoal
• Chagas Disease
• African Sleeping Sickness
• Toxoplasmosis
• Malariae
• Leishmaniasis
• Balantidiasis
• Sarcosporidosis
• Amebiasis

Helminthic
• Trichinosis
• Echinococcosis
• Schistosomiasis
• Ascariasis
• Heterophydiasis

Helminthic
• Filarisis
• Paragonimiasis
• Strongylodiasis
• Cysticercosis
• Visceral larva Migrans

HIV - A completely Seperate
Lecture!!!!!!

Tropical Cardiology

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