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
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