Cardiac Manifestation in Dengue Infection
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Transcript of Cardiac Manifestation in Dengue Infection
RESOURCE PERSON : DR. dr. Soroy Lardo, SpPD. FINASIMDivision of Tropical Medicine and Infectious Diseases
Indonesia Army Central Hospital Gatot Soebroto
Resource person : d. soroy lardo finasim
JOURNAL READING
Nuriza KaruniawanPPDS Kardiologi FKUI
OUTLINE
INTRODUCTION
CARDIAC INVOLVEMENT
VASCULAR INVOLVEMENT
CARDIOVASCULAR THERAPEUTIC TARGET
CONCLUSION
Introduction
Dengue is currently one of the most important emerging infectious diseases in the world
Dengue virus (DENV 1-4), genus Flavivirus, family Flaviviridae
Dengue is transmitted by mosquitoes of the genus Aedes, reported in >100 countries,
High disease burden across South and Southeast Asia
Shock more frequent in children, bleeding and organ impairment more common in adults
Introduction
Mild disease severe(1–5%) organ impairment, bleeding, and plasma leakage (DSS)
The increase in capillary permeability is the best known cardiovascular complication associated with dengue
Other cardiac manifestations : rare fulminant myocarditis to more-common associations with functional myocardial impairment and arrhythmias
Classification System
Clinical Course of Dengue
Cardiac Involvement
Cardiac manifestation of Dengue : impairment myocardial function, arrhythmia, myocarditis
Myocarditis
Dengue Myocarditis
Dengue in elderly
Evidence of cardiac manifestations of Dengue in three perspective
Functional
ECG
Pathology
Functional Studies
Dengue infection is associated with transient, self-limiting myocardial dysfunction
Pathogenic Mechanism Cardiac Dysfunction in Dengue
In majority, direct viral invasion of cardiomyocytes is unlikely
Functional Studies
Fulminant dengue myocarditis might represent a separate phenomenon in which host genetics or increased cardiotropism of the virus allow widespread myocyte infection and damage
Reports of dengue epidemics
DENV 1-3
Primary or secondary DENV infection
Pericardium : dengue pericarditis, pericardial effusion
Increased plasma leakage
Less frequent
ECG Studies in Dengue Infection
ECG changes are often transient and non specific
Bradyarrhythmia : sinus bradycardia, first- and second degree AV Block, VES
Tachyarrhythmia : AF
Non specific ST-T changes
Occur during any phase of the disease and fairly common (30-44%)
Mechanism
Altered autonomic tone
Electrolyte and calcium derangements
Subclinical myocarditis
Clinical relevance remains speculative
Clinical Course of Dengue
VES and Altered Calcium Homeostasis in Dengue
Increased Calcium concentration during diastolic phase in Dengue infection
Functional Studies
Pathological Studies
Histopathological studies limited only in autopsystudies
Results : interstitial oedema, inflammation, andmyocardial necrosis fulminant myocarditis
Dengue capsid protein was demonstrated to bepresent in cardiomyocytes, interstitial cell,myoblast
another finding : clusters of viral particles were
identified inside cardiomyocytes widespreadnecrosis and interstitial oedema
Vascular Involvement
Increased systemic vascular permeability and plasma leakage critical determinant disease severity
Coagulopathy
Endothelial activation
soluble thrombomodulin,
intercellular adhesion molecule 1
vascular cell adhesion protein 1
E-selectin
Clinical Features of Vasculopathy
Increased permeability
Splanchnic Circulatory Changes
Bleeding
Increased Permeability
Profound in children and young adult; lesser degree is difficult to identified
strain gauge plethysmographyassess filtration capacity (Kf)an overall measure of microvascular permeability
A study in Vietnamese children with DSS or DHF without shock
increased Kf in both groups
individual’s compensatory reserve ability to upregulate homeostatic mechanisms to balance the intravascular volume loss
healthy children have higher Kf than healthy adults
higher number of developing capillaries more vulnerable to leakage than mature capillaries
Increased Permeability
evidence ultrasound study
transient increase in capillary permeability (febrile phase,day 2–3)
more common in secondary infections
Another study, similar proportion of patients with primary infections and those with secondary infections (32% and 40%, P = 0.69)
pleural effusions, ascites, and gallbladder wall oedema are commonly present during the critical phase of dengue and correlate with disease severity
plasma leakage seems to be broad (mildsevere) and in primary, or secondary infections, and start earlier than previously understood
Increased Permeability
Capillary leak in DENV infection is slow and persistent narrow pulse pressure
Pulse pressure < 20 mmHg + impaired perfusion DSS
Close observation for signs of plasma leakage is critical from the end of the febrile phase
haemoconcentration, determined by tracking changes in serial haematocrit measurements (insensitive)
Splanchnic Circulatory Dysfunction
An ultrasound study of 45 patients with dengue
a dilated portal vein with lower flow velocity
a higher congestion index
a smaller inferior vena cava in patients with DSS than in those with DF or DHF without shock
(hepatosplanchnic circulatory dysfunction)
Bleeding
Mucosal bleeding, skin pethecie, and bruishing
coagulation abnormalities evolve during the various phases of the infection and correlate with vascular leakage severity rather than bleeding
Mechanism
loss of anticoagulant proteins through capillaries leak
endothelial activation increased thrombomodulin and other procoagulantfactors
viral induction of plasminogen
release of a heparin-like circulating anticoagulant from the microvascular surface
Pathogenesis of Vasculopathy
viral and NS1 interactions with the surface glycocalyx layer
endothelial glycocalyx layer
negatively charged mesh of glycoproteins
Proteoglycans
glycosaminoglycans
glycocalyx layer : primary barrier to the movement of water and other molecules out of the microcirculation
NS1 + heparan sulfate (major glycosaminoglycan)disruption increased vascular permeability.
Cardiovascular therapeutic targets
No antiviral agents
Supportive,cautious fluid resuscitationadequate tissue perfusion during the critical period of capillary leakage
Rarely, inotropic support is required
No cardiac-specific treatments for dengue myocarditis
standard treatment for cardiac failure (β-blockers, angiotensin-converting-enzyme inhibitors, and diuretics
Antiviral and immunomodulatory treatments, interferon beta, corticosteroids, and intravenous immunoglobulins(?)
Cardiovascular therapeutic targets
No benefit with corticosteroids in order to modulate plasma leakage
A study of lovastatin in early dengue is ongoing in Vietnam
antiviral properties
stabilizing and anti-inflammatory effects on the endothelium
upregulation of endothelial nitric oxide synthase might help to restore endothelial function and microvascular tone and integrity
Conclusion
Dengue is broad, ranging from myocardial impairment and arrhythmias to vascular barrier dysfunction causing plasma leakage and haemodynamiccompromise.
Myocardial impairment can contribute to haemodynamic instability during the critical phase of capillary leakage.
Pathogenesis studies are needed to address the underlying mechanisms of capillary leak and endothelial dysfunction so that effective therapeutic targets can be identified
echocardiography should be performed in patients with dengue, particularly in those with severe disease and refractory shock