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Table of Content - Volume 21 Issue 2 - February 2022


 

Clinical study of cardio vascular manifestations in dengue fever

 

Shankaraapp R S

 

Associate Professor, Department of General Medicine, Sri Siddartha Medical College, Tumakuru, Karnataka, INDIA.

Email: sushishyla62@gmail.com

 

Abstract              Background: Dengue is a mosquito-borne viral disease by Flaviviridae family causing wide spectrum of disease ranging from subclinical disease, severe flu-like symptoms to severe dengue associated with severe bleeding, organ impairment, plasma leakage with higher risk of death when not managed appropriately. WHO classifies earlier as DF/ DHF/DSS, at present as Dengue (with or without warning signs) and Severe Dengue. Cardiovascular manifestations in dengue can range from asymptomatic bradycardia to life threatening myocarditis, pulmonary oedema and shock. Sinus bradycardia, transient ventricular arrhythmias, prolonged PR interval, nonspecific ST segment and T wave changes, and transient atrioventricular blocks are some of the ECG findings that can be seen. The virus can be detected by NS1 antigen, ELISA IgM IgG antibodies. Study is planned in south Karnataka to assess the cardiovascular manifestations of dengue fever and to assess the subclinical cardiac involvement in the form of ECG changes in dengue patients. Aims And Objectives: To study the cardiovascular manifestations including subclinical cardiac involvement in the form of ECG changes in serologically confirmed dengue patients. Material And Methods: Prospective observational study conducted for patients more than 15 years with Dengue NS1Antigen positive or IgM/IgG positive. Detailed clinical history, physical examination and laboratory parameters were recorded in a prescribed proforma after taking consent. Cardiovascular manifestations like tachycardia, bradycardia and hypotension are analyzed in all patients including ECG and recorded the findings. Data was entered in Microsoft Office Excel Sheet 2010 and analyzed. Results: There are 150 serologically positive Dengue out 0f which majority 54% are NS1 positive, 65.4% males and 34.6% females, 68.6% % are in 15-40 age 11.3% in 15-20, 33.3% in 21-30and 24% in 31-40age. Commonest clinical presentations along with fever are Headache 71.3%, myalgia 68.6%, nausea and vomiting 41%, arthralgia27%, Warning signs are abdominal pain 16%, bleeding manifestations 5.3%, restlessness 6.3%, altered sensorium 3.3%. Abnormal laboratory parameters are 82.6% thrombocytopenia with 73.3% having platelet < 1 lakh, leucopenia 37.33%, abnormal renal function tests 33.3%, elevated liver enzymes 24%. Conclusion: Commonly noted Cardiovascular manifestations are sinus bradycardia, hypotension and ECG changes. Commonly noted ECG changes are bradycardia, non-specific ST-T changes and Diffuse 'T' Wave Inversions. Cardiovascular involvement is not uncommon but most requires only supportive management. Early recognition of warning signs and meticulous management reduce the morbidity and mortality of dengue.

Key Words: Cardiac manifestations, ECG, Dengue, Severe Dengue, Warning signs.

 

INTRODUCTION

Dengue is a mosquito-borne viral disease caused by a virus of the Flaviviridae family (DENV-1, DENV-2, DENV-3 and DENV-4), transmitted by female mosquitoes mainly Aedes aegypti to a lesser extent, Ae. Albopictus which are also vectors of chikungunya, yellow fever and Zika viruses. Dengue causes a wide spectrum of disease ranging from subclinical disease, severe flu-like symptoms to severe dengue associated with severe bleeding, organ impairment and/or plasma leakage with higher risk of death when not managed appropriately. WHO earlier classifies Dengue as DF/ DHF/DSS.3 Dengue Fever (DF) is a patient having fever with two or more of be following: Headache, Retro-orbital pain, Myalgia, Arthralgia, Leucopenia, mild thrombocytopenia. Dengue Haemorrhagic Fever (DHF) is one having above signs along with one or more of be following: positive tourniquet test, Thrombocytopenia < 100,000, Haematocrit rise ≥ 20%, spontaneous bleeding. Dengue Shock Syndrome (DSS) is one having above signs with circulatory failure weak pulse, hypotension, restlessness or Profound shock with undetectable BP and Pulse.3 WHO also classifies dengue into 2 major categories4: Dengue (with/without warning signs) and Severe Dengue. Dengue fever without warning signs Living in or travel to dengue endemic area presenting with Fever and 2 of the following criteria: Nausea, vomiting, Rash, Aches and pain, positive tourniquet test, Leucopenia, Laboratory confirmed dengue. Dengue fever with warning signs are abdominal pain or tenderness, Persistent vomiting, Clinical fluid accumulation, mucosal bleed, Lethargy, restlessness, Liver enlargement >2cm, Increase in haematocrit with rapid decrease in platelet count.4 Severe dengue is potentially a fatal complication due to plasma leakage, fluid accumulation, respiratory distress, severe bleeding, or organ impairment like heart, kidney, liver or brain which require close observation to avoid complications and risk of death. Uncommon clinical manifestations include acute hepatitis, hepatic failure, acute renal failure, encephalopathy, acute myocarditis.5 Cardiovascular manifestations in dengue can range from asymptomatic bradycardia to life threatening shock, reversible myocardial dysfunction, myocarditis, heart failure including acute pulmonary oedema.6 ECG findings seen are Sinus bradycardia, transient ventricular arrhythmias, prolongation of PR interval, transient atrioventricular blocks and nonspecific ST, T changes. The shock syndrome is due to alteration in capillary permeability with leakage of plasma into extra-vascular spaces associated with immune activation and high serum levels of tumor necrosis factor, interleukin 8 and other factors. The exact mechanism of the cardiac injury is proposed due to direct invasion by the virus and damage to the cardiac cells by the ongoing inflammatory damage. Dengue virus upon its entry in the body is taken up by the macrophages causing activation of the T cells which releases various inflammatory cytokines, interleukins, tumor necrosis factors and activates the complement pathway and histamine leading to the inflammation and necrosis of the endothelial cells, leakage of the plasma causing myocardial interstitial edema leading to impairment of myocardial function. Decreased fluid in the intravascular compartment secondary to plasma leakage leads to alteration in the coronary circulation. 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. The release of these inflammatory markers is more in Severe Dengue that correlates with the higher incidence of cardiac manifestations in Severe Dengue. As there was global increase in number of reported dengue in 2019 India (Karnataka) also reported increase from 99913 (5077) with 220 (9) deaths in 2015, to 157315 (16986) cases with 166(13) deaths in 20197 the present study was taken to study the cardiovascular manifestations including subclinical cardiac involvement in the form of ECG changes in dengue patients presenting to a tertiary care hospital in southern Karnataka during 2019 epidemic.

AIMS AND OBJECTIVES:

To study the cardiovascular manifestations including subclinical cardiac involvement in the form of ECG changes in serologically confirmed dengue patiens.

 

MATERIAL AND METHODS

 It is a prospective observational study conducted for a period of 3 months from November 2019 to January 2020 in the Department of General Medicine, Shridevi Institute of Medical Sciences and research hospital, Tumakuru in southern Karnataka during 2019 epidemic. All patients admitted with laboratory confirmed Dengue NS1 Antigen and or IgM/ IgG antibodies above 15 years of age are included in the study. All Patients on medications like beta-blockers, digoxin affecting the heart rate or rhythm, preexisting cardiac disease were excluded. Detailed clinical history and physical examination were recorded in a prescribed proforma including age, sex, symptoms (fever, headache, arthralgia, nausea, vomiting, pain abdomen, hematuria, bleeding gums, hematemesis), clinical signs (tachypnoea, mucosal bleed, purpuric spots, tourniquet test, tender abdomen, icterus, hepatomegaly, ascites, splenomegaly), cardiovascular signs like tachycardia, bradycardia and hypotension All patients were subjected to ECG and recorded the findings. Patients were analyzed for hemoglobin, haematocrit, leukocyte count, platelet count, Random Blood Sugar, Urine analysis, Liver Function tests, Renal Function tests, Abdominal sonography, Chest radiography, Echocardiography. Patients were managed conservatively with fluid supplementation and platelet transfusion whenever required. Microsoft Excel® 2010 was used for the compilation of data and analyzed the results.

 

RESULTS

During the study period there are 150 cases of Dengue Fever out of which 40 are Dengue without warning signs and 110 are Dengue with warning signs including 30 Severe Dengue. (Table No 1).

TABLE 1:

GRADING OF DENGUE

NO. PATIENTS

PERCENTAGE

Dengue without warning signs

40

26.6 %

Dengue with warning signs

110

73.4 %

Severe Dengue

30

20%

 

During the study 150 patients are serologically positive for Dengue. Among 150, 81(54%) are NS1 positive, 65(43.3%) are IgM positive,59 (39.3%) are IgG positive,22(14.6%) are IgM Dengue + IgG Dengue positive, 15(10%) are NS1 and IgM positive, 13(8.6%) are NS1, IgG, IgM positive, 5(3.3%) are NS1 and IgG positive (Table 2).

TABLE 2: Dengue serology report of patients

Dengue serology

No. of patients

percentage

NS1 antigen

81

54%

IgM Dengue

65

43.3%

Ig G Dengue

59

39.3%

NS1 antigen + IgM Dengue

15

10%

NS1 antigen + IgG Dengue

5

3.3%

IgM Dengue + IgG Dengue

22

14.6%

NS1 antigen+ IgM Dengue + IgG Dengue

13

8.6%

 

There are patients from 15 to 75 years of age with highest incidence in the age group of 15-30 years in 67 cases followed by 36 cases in 31-40 years, 29 in 41- 50, 10 cases in 51-60 years and 8 in 61-75 years. Majority (69%) are in 15 to 40 years with 33.3% in 21-30, 24% in 31-40, 19.3% in 41-50, only 5% in >60 years (Table No 3).

TABLE 3: Age distribution of patients

AGE GROUP

MALE

FEMALE

TOTAL

PERCENTAGE

15 TO 20 YEARS

12

05

17

11.3%

21 TO 30 YEARS

37

13

50

33.3%

31 TO 40 YEARS

25

11

36

24%

41 TO 50 YEARS

16

13

29

19.3%

51 TO 60 YEARS

04

06

10

6.6%

61 TO 75 YEARS

04

04

08

5.3%

 

There are 98 males (65.3%) with majority 74 (75.5%) in the age group of 15-40 years and only 4 in elderly of more than 60 years and 52 females (34.6%) with majority 29(55.7%) in the age group of 15-40 ears and only 4 in elderly of more than 60 years. (Table 4).

TABLE 4: Gender distribution of patients

SEX

MALE

FEMALE

15 TO 40 YEARS

74(75.5%)

29(55.7%)

41 TO 60 YEARS

20

19

61 TO 75 YEARS

04

04

TOTAL PATIENTS

98(65.4%)

52(34.6%)

The commonest clinical presentations are fever in all followed by Headache in 107, myalgia in 103, nausea and vomiting in 61, arthralgia in 41 patients. The commonest warning signs are abdominal pain in 24, restlessness in 10, bleeding manifestations in 8, altered sensorium in 5 cases. (Table No 5).

TABLE 5: Commonest clinical manifestations with warning signs

CLINICAL

MANIFESTATIONS

TOTAL CASES

150

PERCENTAGE

 

HEADACHE

107

71.3%

MYALGIA

103

68.6%

NAUSEA/VOMITING

61

40.6%

ARHRALGIA

41

27.3%

ABDOMINAL PAIN

24

16 %

RESTLESSNESS

10

6.6%

BLEEDING MANIFESTATION

08

5.3%

ALTERED SENSORIUM

05

3.3%

 

Commonest Laboratory parameters observed are leucopenia in 56, hematocrit rise in 28, abnormal renal function tests in 50, elevated liver enzymes in 36 and hyperbilirubinemiain 10 cases. (Table No 6).

TABLE 6: Commonest Abnormal Laboratory Parameters

LABORATORY PARAMETERS

TOTAL CASES

150

PERCENTAGE

 

MILD THROMBOCYTOPENIA

MOD THROMBOCYTOPENIA

SEVERE THROMBOCYTOPENIA

124

110

76

82.6%

73.3%

50.6%

LEUCOPENIA

56

37.3%

RENAL FUNCTION TESTS

50

33.3%

ELEVATED LIVER ENZYME

36

24 %

HAEMATOCRIT

28

18.6%

HYPERBILIRUBINAEMIA

10

6.6%

 

Commonest cardiovascular signs are bradycardia in 35, tachycardia in 4, hypotension SBP less than 100mmHg in 63 with 24 having SBP less than 90 mmHg. and ECG changes in 66 cases(Table No 7).

Table 7: Commonest cardiovascular signs

CARDIOVASCULAR SIGNS

TOTAL CASES

150

PERCENTAGE

 

BRADYCARDIA

35

23.3%

TACHYCARDIA

04

2.6 %

HYPOTENSION SBP<100mmHg

SBP<90 mmHg

 

63

24

 

42%

16%

ECG CHANGES

66

44%

 

Commonest ECG changes observed in 66 out of 150 cases. The commonest ECG changes observed in the study are sinus bradycardia in 35 (53%), sinus tachycardia in 4(6%), non-specific ST-T changes in 12(18%), new onset right bundle branch block and 10 A V block in 2 (3%) each, ST-T changes in 12(18%) and Diffuse 'T' Wave Inversion in 4(9%). (Table No 8).

Table 8: Commonest ECG changes

ECG CHANGES

TOTAL CASES 66

PERCENTAGE

SINUS BRADYCARDIA

35

53%

SINUS TACHYCARDIA

4

6 %

A V BLOCK 10

2

3 %

RBBB

2

3 %

ST-T CHANGES

12

18 %

DIFFUSE ‘T‘ INVERSION

6

9 %

+There was no mortality in the study. Platelet transfusion done in 34(22%) cases.

 

DISCUSSION

During our study period 150 serologically positive Dengue patients are analyzed. Majority 54% are NS1 positive which correlates with studies by Patta Apparao 50.3%,8 Vidyadhara Rani 63%,9 Abhinandya Mukhopadhya 64%,10 Girish 70%,11 followed by 43.3% IgM positive cases. There are 10% NS1 and IgM positive which correlates with studies by Patta Apparao 25.2%,8 Vidyadhara Rani 5%,9 by Girish 11%.11 Majority of patients 68.6% are in 15-40 years group (11.3% in 15-20, 33.3% in 21-30, 24% in 31-40) which correlates with studies by Naveen 68%,12 Parag Viren Papalkar 58.33%,13 Sachin14 59% in 21-40 years, Sukhwani N16 76.8% in 16-35 years, followed by 19.3% in 41-50 years, only 5% in >60 years. Majority are male 65.4% and 34.6% are females which is similar in most of the studies 64%- 36% by Abhinandya Mukhopadhya,10 61.46%-3 8.53% by Vidyadhara Rani,9 59%-41% by Girish,11 56%-44% by Naveen,12 64%-36% by RakeshKumarYadav,15 62.1%- 37.9% by Sukhwani N.16 The commonest clinical presentations are Headache in 71.3%, myalgia in 68.6%, nausea and vomiting in 40.6%, arthralgia in 27.3% compared to studies by Naveen12 headache (68%) myalgia (72%) nausea and vomiting (31%) arthralgia 43% by Sachin14 headache (55%) nausea (46%) myalgia (56%). Abdominal pain present in 16% compared to 33% by Naveen,12 Bleeding manifestations in 5.3% compare to 8% by Girish,11 16% by Sachin,14 10% by RakeshKumarYadav,15 13.5% by Sukhwani N.16 The commonest abnormal laboratory parameters observed are 82.6% thrombocytopenia similar to 82% by Sachin,14 with 73.3% having platelet < 1 lakh similar to 74% by Naveen,12 77.2% by Girish,11 and 77.2% by vidyadar rani.9 There are 50.6% severe thrombocytopenia of platelet < 0.5 lakh compared to 61% by vidyadar rani. There are Leucopenia in 37.3% compared to 53% by Naveen,12 62% by Girish,11 abnormal renal function tests in 33.3% compared to 22% by Sachin,14 20% by RakeshKumarYadav,15 elevated liver enzymes in 24 % compared to27 % by Girish,11 53% by Sachin14 and hyperbilirubinemia in 6.6% cases compared to 12% by Sachin.14 The commonest cardiovascular signs are bradycardia in 23.3% compared to 39% by Naveen, tachycardia in 2.6% compared to 2% by Naveen, 14% by RakeshKumar Yadav,15 hypotension SBP less than 100mmHg in 42%, compared to 25% by RakeshKumarYadav,15 SBP less than 90 mmHg in 16% and ECG changes in 44% compared to 56.5% by Sukhwani N,16 35% by Parag Viren Papalkar,13 48.14% by AmitKrishna.17 The commonest ECG changes observed in the study are sinus bradycardia in 53% compared to 69% by Parag Viren Papalkar,13 60% by RakeshKumar Yadav,15 15.5% by Sukhwani N,16 31.48% by AmitKrishna,17 Sinus tachycardia in 6% compared to 3.92% by Parag Viren Papalkar,13 14% by Rakesh Kumar Yadav,15 3.70% by AmitKrishna,17 Non-specific ST-T changes in 18% compared to 15.3% by Parag Viren Papalkar,13 15.5% by Sukhwani N,16 11.11% by AmitKrishna,17 New onset Right Bundle Branch Block in 3% compared to 1.85% by AmitKrishna,17 10 A V block in 3% compared to 11% by RakeshKumar Yadav,15 Diffuse 'T' Wave Inversion 9% compared to 13.8% by by Sukhwani N.16

 

CONCLUSION

Involvement of multiple organs in Dengue fever resolves spontaneously. Cardiovascular involvement is not uncommon and is encountered in large numbers of cases. Clinical manifestations vary widely from silent disease to severe Dengue. ECG changes are noted in both symptomatic and asymptomatic patients but all ECG changes were reversible and no patient died in our study. Commonly noted Cardiovascular manifestations are sinus bradycardia, hypotension and ECG changes. Commonly noted ECG changes are bradycardia in, non specific ST-T changes and Diffuse 'T' Wave Inversions. Most requires only supportive management. Early recognition of warning signs and meticulous management reduce the morbidity and mortality of dengue.

 

REFERENCES

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