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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 233-236

A rare case of dengue myocarditis masquerading as st-segment elevation myocardial infarction: A Balance Approach


Department of Cardiology and Medicine, Aayush Hospitals, Vijayawada, Andhra Pradesh, India

Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. P S S. Chowdary
Department of Cardiology, Aayush Hospitals, Vijayawada - 520 008, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_46_19

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  Abstract 


Dengue illness is a serious public health problem, contributing to significant morbidity and mortality. Cardiac involvement is common and is encountered in centers handling large numbers of dengue cases. Dengue myocarditis masquerading as ST-segment elevation myocardial infarction (STEMI) is a very rare presentation and only a few cases of dengue myocarditis masquerading as STEMI have been reported; it poses several challenging problems, as these patients are at high-risk bleeding and ischemic complications. Our case highlights the importance of the balance approach in the management of the bleeding and ischemic complications in a rare case of dengue myocarditis presenting as STEMI and the role of cardiac magnetic resonance imaging in determining the prognosis of the patient.

Keywords: Dengue hemorrhagic fever, dengue shock syndrome, dengue virus, regional wall motion abnormality, ST-segment elevation myocardial infarction


How to cite this article:
Subrahmanya Sarma VR, Madhavi G, Gopalakrishna K, Raghuram P, S. Chowdary P S, Somasekhar G, Purnachandrarao K, Boochibabu M, Prasad M, Sasidhar Y. A rare case of dengue myocarditis masquerading as st-segment elevation myocardial infarction: A Balance Approach. J Indian coll cardiol 2019;9:233-6

How to cite this URL:
Subrahmanya Sarma VR, Madhavi G, Gopalakrishna K, Raghuram P, S. Chowdary P S, Somasekhar G, Purnachandrarao K, Boochibabu M, Prasad M, Sasidhar Y. A rare case of dengue myocarditis masquerading as st-segment elevation myocardial infarction: A Balance Approach. J Indian coll cardiol [serial online] 2019 [cited 2020 Apr 6];9:233-6. Available from: http://www.joicc.org/text.asp?2019/9/4/233/280349


  Introduction Top


Dengue fever is a serious global public health problem, with 2.5 billion people at risk and an annual range of 50–390 million infections. India contributed to 34% of the 96 million apparent dengue virus (DENV) infections estimated to have occurred globally in 2010.[1] Most Indian states have been classified as having frequent or continuous risk of dengue transmission.[2]

Infection may be asymptomatic or present with a broad range of clinical manifestations ranging from a self-limiting febrile course to severe forms such as dengue hemorrhagic fever or dengue shock syndrome.[3] Cardiac involvement in dengue fever is rare and it exists in severe forms of disease. Here, in this case report, we describe a rare presentation of dengue illness with cardiac involvement presenting as acute ST-segment elevation myocardial infarction (STEMI).


  Case Report Top


A 22-year-old male presented with fever for 4 days, vomiting, and diarrhea for 2 days. On examination, he had erythematous, blanchable rash over the chest and extremities; investigative work up showed that he had dengue fever (Dengue Ns1 Ag positive, IgM antigen positive). He also had leukopenia (total leucocyte count [TLC]-2600/mm3) and thrombocytopenia, with all other tests being normal; hence, the patient was treated with IV saline infusion, antibiotics, and other supportive medication. Subsequently, his platelet count reached a trough level of 80,000 in the next day 2 days; he was continued on the supportive medication. During his intensive care unit stay, he developed hypotension and chest pain. Electrocardiogram (ECG) showed ST-segment elevation in I, AvL, reciprocal diffuse ST-segment depression in inferior, anterior leads [Figure 1], echo at that time showed regional wall motion abnormality of left circumflex (LCX) and right coronary artery (RCA) territory, moderate-to-severe left ventricular (LV) dysfunction (ejection fraction – 33%) [Video 1], his troponins were elevated (724.3 ng/l), renal and liver functions were normal, he was started on statins, single antiplatelet aspirin was started, he was quickly stabilized, coronary angiography was done; it showed that all his coronaries (Left main [LM], left anterior descending, left circumflex [LCX], right coronary artery [RCA]) were normal [Figure 2], [Figure 3], [Figure 4]. In view of his prolonged hypotension and severe LV dysfunction, cardiac magnetic resonance imaging (MRI) was not done. Antiplatelets and statins were stopped. He was clinically diagnosed as dengue fever with myocarditis mimicking the STEMI was made. The patient continued supportive medication, his condition gradually improved, his platelet counts and leukcocyte counts became normal, and LV function also improved. Antiplatelets were stopped and statins were also stopped at the time of discharge. In the follow-up after a week, cardiac MRI was done. It showed [Figure 5] and [Figure 6] and Video 2] a mildly dilated left ventricle, with mild-to-moderate LV dysfunction. There is late gadolinium enhancement (LGE) in the interventricular septum not restricting to any arterial distribution. These findings supported the diagnosis of myocarditis based on the European Society of Cardiology (ESC) working group on myocardial and pericardial diseases expert consensus group diagnostic criteria[4] [Figure 7]. Till now, the patient had 1-month follow-up which is uneventful.
Figure 1: Electrocardiogram showing ST elevation in lateral leads (I, AVL) reciprocal ST depression in inferior leads, anterior leads (II, III, AVF, V1–V6)

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Figure 2: Anterior–posterior cranial view showing normal left anterior descending

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Figure 3: Anterior–posterior caudal image showing normal left circumflex

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Figure 4: Left anterior oblique image showing nondominant normal right coronary artery

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Figure 5: Late gadolinium enhancement in a T1-weighted image showing patchy enhancement in the mid-myocardial layers of interventricular septum

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Figure 6: Late gadolinium enhancement in a T1-weighted image showing patchy enhancement in the mid myocardial layers of interventricular septum and lateral wall of left ventricular

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Figure 7: The diagnostic criteria of clinically suspected myocarditis in the absence of endomyocardial biopsy

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  Discussion Top


Dengue is one of the most important mosquito-borne illnesses worldwide.[5] It is caused by a flavivirus with four distinct serotypes (DENV1, DENV2, DENV3, and DENV4). The natural history of dengue infection usually follows a clear pattern. The majority of infections are asymptomatic and subclinical. Symptomatic disease follows an incubation period of 4–7 days following which it will enter febrile phase, critical phase, and later convalescence phase.[6] In November 2009, the World Health Organization issued a new guideline that classifies symptomatic cases as dengue or severe dengue, as the previous classification failed to identify a substantial proportion of severe dengue cases.

Dengue is defined by a combination of ≥2 clinical findings in a febrile person who traveled to or lives in a dengue-endemic area. Clinical findings include nausea, vomiting, rash, aches and pains, a positive tourniquet test, leukopenia, and the following warning signs: abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, restlessness, and liver enlargement. Severe dengue is defined by dengue with any of the following symptoms: severe plasma leakage leading to shock or fluid accumulation with respiratory distress; severe bleeding; or severe organ impairment such as elevated transaminases ≥1000 IU/L, impaired consciousness, or heart impairment.

Cardiac involvement is common and is encountered in centers handling large numbers of dengue cases. Clinical manifestations of cardiac involvement can vary widely, from silent disease to severe myocarditis resulting in death. Rhythm abnormalities, arrhythmias, myocarditis, myocardial depression with symptoms of heart failure and shock, and pericarditis have been reported.[7] Only a few cases of dengue myocarditis mimicking an STEMI have been reported previously in the literature by Deshwal[8] and Patra et al.[9] Our case highlights the presentation of dengue myocarditis as STEMI and its management in a patient with high risk for bleeding, in contrast to the previous authors. There are several treatment challenges involved with STEMI presentation of dengue myocarditis, particularly the bleeding risk. This is the reason why fibrinolytics, anticoagulants, dual antiplatelets were not given in our case as it may be counterproductive, and hence early invasive strategy was followed to know coronary anatomy in our patient to reduce the bleeding complication rates. The diagnosis of the myocarditis without endomyocardial biopsy in a suspected case can be done with the help of ESC working group on myocardial and pericardial diseases expert consensus group diagnostic criteria [Figure 7]. It has two segments: one is the proper clinical scenario (symptoms of chest pain/breathlessness/palpitations/unexplained cardiogenic shock) and the other is diagnostic criteria (includes the changes in ECG/cardiac biomarkers/functional imaging either by echo or MRI/cardiac tissue characterization by cardiac magnetic resonance). Myocarditis can be diagnosed by the presence of appropriate clinical presentation along with the presence of changes in each of the diagnostic modality as described. Our case also highlights the fact that cardiac MRI done in the follow-up helps in identifying the persisting features of myocarditis when the echocardiographic changes reverted back to normal [Video 3]. LGE in the mid-myocardial layers showing the presence of myocardial fibrosis and moderate LV dysfunction with mildly dilated ventricle, suggests that the patient needs a close follow-up for further events. The exact mechanism of the cardiac injury and its STEMI presentation of dengue myocarditis remain unknown; however, it is proposed that the direct invasion of the cardiac myocyte by the virus and damage to the cardiac cells by the inflammatory mediators are the two major mechanisms of the cardiac manifestations. DENV upon entry into the body, is taken up by the macrophages which causes activation of the T-cells and they in turn the release of several inflammatory mediators such as, interleukins (IL-1, IL-2, and IL-6), tumor necrosis factors, activation of the complement pathway (C3a and C5a) and histamine, and other inflammatory cytokines. This causes inflammatory - mediated damage of endothelial cells, plasma leakage leading to myocardial interstitial edema and myocardial dysfunction. Various inflammatory markers released cause direct suppression of the cardiac contractility and alteration in the electrical conduction of heart leading to various conduction blocks and ventricular arrhythmia. Severe plasma leakage causes reduced intravascular volume and alterations in the coronary microcirculation and its dysfunction. The release of inflammatory markers, subsequently plasma leakage is more in severe dengue, these patients will have high chance of having cardiac manifestations.




  Conclusion Top


Dengue myocarditis should be thought of whenever patient presents with the features suggestive of STEMI in the background of dengue illness. Antiplatelets and anticoagulants in dengue patients should be judiciously used, early invasive strategy in these patients may help to avoid complications. Cardiac MRI in the follow-up may help to identify the prognosis of the patient.

Acknowledgments

The authors would like to acknowledge the fact that this case report has not been published or submitted to any journal previously and this is original data. The authors would also like to thank Aayush Hospitals for its technical help.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 1
    
2.
Jentes ES, Lash RR, Johansson MA, Sharp TM, Henry R, Brady OJ, et al. Evidence-based risk assessment and communication: A new global dengue-risk map for travellers and clinicians. J Travel Med 2016;23. pii: taw062.  Back to cited text no. 2
    
3.
World Health Organization, Regional Office for South-East Asia. Comprehensive Guideline for Prevention and Control of Dengue and Dengue Haemorrhagic Fever. Revised and expanded edition. SEARO, New Delhi: WHO Regional Office for South-East Asia. 2011.   Back to cited text no. 3
    
4.
Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013;34:2636-48, 2648a-2648d.  Back to cited text no. 4
    
5.
Raheel U, Faheem M, Riaz MN, Kanwal N, Javed F, Zaidi Nu, et al. Dengue fever in the Indian subcontinent: An overview. J Infect Dev Ctries 2011;5:239-47.  Back to cited text no. 5
    
6.
World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. World Health Organization; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf. [Last accessed on 2014 Dec 20].  Back to cited text no. 6
    
7.
Gupta N, Kulkarni AV, Sinha N, Jhamb R, Gulati S. Dengue hemorrhagic fever complicated with encephalopathy and mycocarditis. J Commun Dis 2010;42:297-9.  Back to cited text no. 7
    
8.
Deshwal R. Dengue myocarditis presenting as ST segment elevation MI. J Assoc Physicians India 2019;67:91-2.  Back to cited text no. 8
    
9.
Patra S, Bhardwaj G, Manohar JS, Srinivasa KH, Kharge J, Manjunath CN. Acute myocardial infarction being the presentation of dengue myocarditis. J Cardiovasc Dis Res 2013;4:159-61.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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