title: Evaluation of cardiac involvement during dengue viral infection.
abstract: BACKGROUND
  Dengue is a disease whose clinical manifestations range from asymptomatic infections to a severe disease. There have been some previous reports of myocardial involvement in dengue, but this association has not been completely established.
  
  
  METHODS
  From January to July of 2011, patients hospitalized with dengue, confirmed through dengue nonstructural protein 1 and/or immunoglobulin M detection, were included in this study and troponin I and N terminal fragment of B-type natriuretic peptide levels were determined. Patients with abnormal biomarkers underwent echocardiography and when any abnormality was detected, they underwent cardiac magnetic resonance imaging.
  
  
  RESULTS
  Eighty-one patients were evaluated and 12 patients (15%) presented with elevated biomarker levels. Compared to controls, they had higher leukocyte (P < .001) and platelet counts (P = .005); higher C-reactive protein (P = .02), and a lower viral load (P = .03). There was no difference according to clinical dengue classification; dengue hemorrhagic fever/dengue shock syndrome severity; duration of symptoms; or prevalence of secondary infection between the 2 groups. Two patients died secondary to cardiogenic shock before imaging studies. Necroscopic findings were compatible to myocarditis in both, and immunohistochemistry for dengue virus showed increased staining on mononuclear cells located in the myocardial tissue. Of the 10 patients who underwent echocardiography, depressed left ventricular ejection fraction (LVEF) was identified in 1, left ventricular segmental abnormalities with preserved LVEF in 2, and an important pericardial effusion with tamponade in another. Cardiac involvement was confirmed by CMR in these 4 patients.
  
  
  CONCLUSIONS
  Dengue viruses were shown to cause cardiac disease with clinical manifestations ranging from mild elevation of biomarkers to myocarditis and/or pericarditis.
authors.affiliation: Department of Internal Medicine, University of São Paulo Medical School at Ribeirão Preto, São Paulo, Brazil
authors.forename: Carlos Henrique
authors.initials: CH
authors.lastname: Miranda
authors.forename: Marcos de Carvalho
authors.initials: Mde C
authors.lastname: Borges
authors.forename: Alessandra Kimie
authors.initials: AK
authors.lastname: Matsuno
authors.forename: Fernando Crivelenti
authors.initials: FC
authors.lastname: Vilar
authors.forename: Luís Gustavo
authors.initials: LG
authors.lastname: Gali
authors.forename: Gustavo Jardim
authors.initials: GJ
authors.lastname: Volpe
authors.forename: André
authors.initials: A
authors.lastname: Schmidt
authors.forename: Antônio
authors.initials: A
authors.lastname: Pazin-Filho
authors.forename: Fernanda Miquelitto Figueira da
authors.initials: FM
authors.lastname: Silva
authors.forename: Luiza Antunes de
authors.initials: LA
authors.lastname: Castro-Jorge
authors.forename: Mayra Fernanda de
authors.initials: MF
authors.lastname: Oliveira
authors.forename: Fabiano
authors.initials: F
authors.lastname: Saggioro
authors.forename: Roosecelis Brasil
authors.initials: RB
authors.lastname: Martines
authors.forename: Benedito Antônio Lopes da
authors.initials: BA
authors.lastname: Fonseca
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002648:Child; D002675:Child, Preschool; D003715:Dengue / Q000097:blood / Q000503:physiopathology*; D003716:Dengue Virus / Q000302:isolation & purification*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000097:blood / Q000821:virology*; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D011446:Prospective Studies; D012770:Shock, Cardiogenic / Q000097:blood / Q000821:virology; D019210:Troponin I / Q000097:blood; D019562:Viral Load
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D019210:Troponin I; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
keywords: cardiac biomarkers; cardiogenic shock; dengue; myocarditis