Dengue Myopericarditis Mimicking Acute Myocardial Infarction.

نویسندگان

  • Kollengode Ramanathan
  • Lynette Teo
  • Wong Ching Chiew Raymond
  • Graeme MacLaren
چکیده

A 33-year-old woman presented to the emergency department with giddiness. She had a history of fever and vomiting 4 days before, which had completely resolved. Her medical history was otherwise unremarkable. She was leuko-penic (leukocyte count 4.6×10 9 /L), lymphopenic (0.47×10 9 /L), and thrombocytopenic (89×10 9 /L), and she remained hypoten-sive (mean arterial pressure, 45 mm Hg) despite 3 L of fluid resuscitation. A 12-lead ECG showed hyperacute ST changes in the inferolateral leads (Figure 1). She was initially commenced on intravenous norepinephrine and epinephrine that was later changed to dobutamine. A transthoracic echocardio-gram (Figure 2) revealed severe global left ventricular dys-function (ejection fraction, ≈20%) with moderate pericardial effusion and no cardiac tamponade (Movies I and II in the online-only Data Supplement). The serum troponin I level was 9.3 μg/L (reference range <0.039 μg/L). This rose to 11.3 μg/L within 12 hours. Given the clinical, biochemical, and echocardiographic findings, she was evaluated for viral myo-carditis and was shifted to the intensive care unit for observation and consideration of early mechanical cardiac support. The dengue nonstructural protein (NS1) serology was positive , and subsequent serotyping showed she had dengue virus serotype-2 (DEN-2). Cardiac MRI showed severely impaired left ventricle systolic function (ejection fraction, 19%; cardiac index, 1.12 L·min –1 ·m –2). There was diffuse subepicar-dial enhancement at the midcavity and apical levels in the late gadolinium sequence with a moderate-sized pericardial effu-sion (Figures 3 and 4). The patient developed ischemic hepatitis and bilateral lower limb petechiae with falling platelet counts (to 49×10 9 /L). However, serial hematocrit measurements remained stable, suggesting no signs of ongoing hemorrhage. She required intermittent noninvasive ventilation for acute heart failure. However, her inotropes were successfully weaned after 5 days, and she was subsequently transferred to the general ward. A follow-up transthoracic echocardiogram (Figure 5) showed improved left ventricular function (ejection fraction, 65%) with left ventricular wall thickening and no pericar-dial effusion (Movies III, IV, and V in the online-only Data Supplement). Dengue is an emerging global infectious disease and atyp-ical manifestations are increasingly being reported. Dengue is an arboviral disease caused by a flavivirus transmitted by the Aedes aegypti mosquito. Dengue virus has 4 antigenically distinct serotypes (DEN 1, DEN 2, DEN 3, and DEN 4), and the disease is endemic in South and Southeast Asia, Central and Latin America, and Africa. The World Health Organization estimates that 40% of the world's population living in …

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عنوان ژورنال:
  • Circulation

دوره 131 23  شماره 

صفحات  -

تاریخ انتشار 2015