Ref Number = ASPR0020
Cardiovascular manifestation of Dengue infection
Eka Gunawijaya, Ni Putu Veny Kartika Yantie
Department of Child Health, Medical Faculty, University of Udayana
Integrated Cardiovascular Services, Sanglah General Hospital, Denpasar, Bali
E-mail: ekagunawijaya@yahoo.com
Dengue is an important mosquito-borne viral disease in many tropical countries. The cardiac involvement as complication in dengue are not common. The pathogenesis is believed through two probable mechanisms of direct viral invasion into the cardiac tissue, and circulating immune complex affecting cardiac tissue. Between 4 different dengue virus types, DENV-1, 2 and 3 are responsible for cardiac dengue.1, 2, 3, 4  There is no report related to DENV-4.
Dengue myocarditis is the most common documented cardiac pathology in dengue, however only a few cases are reported in the medical journals. There is a probable reason for the low incidence of dengue myocarditis that it might represented the rarity of the cases or in the other options might be due to under diagnosis or neglecting to report. It was believed that such myocarditis was very rare and might not be fatal if conduct early diagnosis and treatment.5 The severe forms of dengue myocarditis that had been reported were associate with severe degree heart block, pulseless ventricular tachycardia, and acute myocardial infarction.6 Between all carditis, dengue endocarditis have never been reported. Indeed, the formed immune complex in dengue infection could not be entrapped in the endocardial layer, including cardiac valve. Dengue pericarditis can be seen but it is very rare than myocarditis incidence, and it will only present as the form of combine myopericarditis, no report of isolated dengue pericarditis.6,7 The fatal form of dengue pericarditis is associate with cardiac tamponade. The pathogenesis is believed to be the extension of dengue myocarditis into the pericardium rather than circulating immune complex. At present, dengue pericarditis is extremely rare due to early diagnosis of dengue myocarditis.
There is no specific treatment for severe cardiac dengue in many journal reports, just do a supporting cardiac treatment due to different cardiac problems, and wait for the spontaneous improvement as same as a typically self limiting disease in dengue infection. In several case report, there were various cardiac treatment given to the patients. In a case with pulseless ventricular tachycardia following an episode of total AV block in USA at 2016, a successful treatment had been performed with placing a temporary transvenous atrial sensed ventricular pacemaker.8 A similar case in India at 2015 with pulseless ventricular tachycardia received amiodarone bolus then continued with maintenance dose.9 Another severe case with cardiac tamponade had been reported in Brazil at 2017, she finally survived after pericardial tapping and received 400 mg/kg/day intravenous immunoglobulin for 3 days.10 
 Myocarditis is asymptomatic in the majority of patients with dengue, and diagnosis or treatment in the absence of clinical features is unnecessary.7, 11 Thus, routine echocardiography is not warranted. Patients with ECG changes and those with features of clinical heart failure should have an echocardiogram done. The biggest dilemma is determining whether, in a patient with shock, myocarditis is playing a contributory role. There are no clear guidelines regarding this, the presence of ECG changes should alert the treating clinician to the possibility of associated myocarditis. On most occasions, myocarditis occurring in dengue is not clinically significant. Where suspicion is strong, echocardiography will be helpful if available.12 Supportive care includes optimal intravascular volume maintenance with intravenous fluids, judicious use of diuretics where indicated, and inotropic support where necessary.13, 14  In particular, if myocardial involvement is suspected, care should be taken not to cause iatrogenic fluid overload. Much of the evidence suggests that myocarditis is transient and self-limiting. The current evidence base does not support the use of corticosteroids or immunoglobulins in treating severe dengue. Correction of serum calcium derangements to optimize cardiac status is usually carried out, but there is currently no evidence of its benefit.
Keywords: cardiovascular, myocarditis, dengue infection
1. Shivanthan MC, Navinan MR, Constantine GR, Rajapakse S. Cardiac involvement in Dengue infection. J Infect Dev Ctries 2015;9:338-46.
2. Miranda CH, Borges MDC, Matsuno AK, Vilar FC, Gali LG, Volpe GJ, et al. Evaluation of cardiac involvement during dengue viral infection. CID 2013;57:812-9.
3. Marques N, Gan VC, Leo YS. Dengue myocarditis in Singapore: two case reports. Infection 2013;41:709-14.
4. Kularatne SAM, Pathirage MMK, Medagama UAB, Gunasena S, Gunasekara MB. Myocarditis in three patients with dengue virus type DEN-3 infection. Ceylon Medical Journal 2006;51:75-6.
5. Satarasinghe RL, Arultnithy K, Amerasena NL, Bulugahapitiya U, Sahayam DV. Asymptomatic myocardial involvement in acute dengue virus infection in a cohort of adult Sri Lankans admitted to a tertiary referral centre. Br J Cardiol 2007;14:171-3.
6. Li Y, Hu Z, Huang Y, Lic J, Hong W, Qin Z, et al. Characterization of the myocarditis during the worst outbreak of dengue infection in China. Medicine 2016;27:1-6.
7. Gulati S, Maheshwari A. Atypical manifestations of dengue. Tropical Medicine and International Health 2007;12:1087-95.
8. Virk HUH, Inayat F, Rahman ZU. Complete Heart Block in association with Dengue Hemorrhagic Fever. Korean Circ J 2016;46:866-9.
9. Mohammed MZ, Venugopal K, Kadappa J, Bharathraj MY, Anudeep R. Ventricular Tachycardia in Dengue Fever. IJPCR 2015;7:162-3.
10. Fernandes AIV, Mendes CL, Simoes RH, Silva AEVF, Madruga CB, de Brito CAA, et al. Cardiac tamponade in a patient with severe dengue fever. Rev Soc Bras Med Trop 2017;50.
11. Yantie NPVK, Gunawijaya E, Suradipa IW, Gustawan IW. Asymptomatic cardiac rhythm abnormality in children with dengue virus infection. Bali Med J 2016;5:177-80.
12. Yacoub S, Wertheim H, Simmons CP, Screaton G, Wills B. Cardiovascular manifestations of the emerging dengue pandemic. Nature Reviews Cardiology 2014;11:335-45.
13. Buntubatu S, Prawirohartono EP, Arguni E. Myocarditis prevalence in paediatric dengue infection: a prospective study in tertiary hospital in Yogyakarta. Journal of Tropical Pediatrics 2019;1:1-6.
14. Salgado DM, Eltit JM, Mansfield K, Panqueba C, Castro D, Vega MR, et al. Heart and skeletal muscle are targets of dengue virus infection. Pediatr Infect Dis J 2010;29:238-42.
Disclaimer: The Views and opinions expressed in the articles are of the authors and not of the journal.
Journal Office
Mid City Hospital, 3-A Shadman II
Jail Road, Lahore ,Pakistan
Managing Editor
Dr. Intan Juliana Abd Hamid
Support & Help
Assistant Editor
Dr. Sadia Shabbir Hussain
Support & Help
Digital Content Editor
Dr. Khalid Masud