title: Complete heart block in dengue complicating management of shock due to both bleeding and leakage: a case report.
abstract: BACKGROUND
  The spread of Dengue virus infection is reaching pandemic proportions. Dengue is usually dreaded for causing shock due to capillary leakage. However the clinical spectrum of dengue is vast and the newly incorporated expanded dengue syndrome introduces a wide range of presentations that are rarely observed and appreciated but nevertheless have the potential to cause significant morbidity and even mortality. Cardiac involvement in dengue is one such example.
  
  
  METHODS
  A 26 year old South-Asian female presented in a state of haemodynamic shock with a history of fever and use of non-steroidal anti inflammatory drugs. Dengue was suspected clinically and later confirmed. Following stabilization and while still in the febrile phase the patient developed bradycardia with dynamic electrocardiogram changes which evolved into complete heart block. However there was no circulatory compromise. Clinical picture was further complicated by the development of dengue haemorhaghic fever and cautious fluid resuscitation was carried out in correlation to clinical and haematological parameters. Impaired coagulation profile necessitated administration of activated factor seven on the backdrop of low platelets and bleeding. Cardiac pacing could be avoided due to maintenance of vitals within acceptable parameters.
  
  
  CONCLUSIONS
  Expanded dengue syndrome should be given greater appreciation as not all may be benign. Cardiovascular system involvement in dengue has the potential to cause significant morbidity and mortality. Careful interpretation of clinical parameters will help in the institution of the appropriate management and help avoid unnecessary invasive interventions. Screening of dengue patients with timely electrocardiographs would be useful to detect cardiac involvement. Guidance on managing atypical manifestations of dengue expanded syndrome should available to help clinicians dictate treatment.
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. rayno.navinan@gmail.com.
authors.forename: Mitrakrishnan Rayno
authors.initials: MR
authors.lastname: Navinan
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. yudhishdran@yahoo.com.
authors.forename: Jevon
authors.initials: J
authors.lastname: Yudhishdran
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. sandaherath@yahoo.com.
authors.forename: Sandamalee
authors.initials: S
authors.lastname: Herath
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. isurujith@gmail.com.
authors.forename: Isurujith
authors.initials: I
authors.lastname: Liyanage
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. ktharshana@gmail.com.
authors.forename: Tharshana
authors.initials: T
authors.lastname: Kugadas
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. daam293@gmail.com.
authors.forename: Damith
authors.initials: D
authors.lastname: Kumara
authors.affiliation: National Hospital of Sri Lanka, Colombo, Sri Lanka. kulatunga.aruna@yahoo.com.
authors.forename: Aruna
authors.initials: A
authors.lastname: Kulatunga
mesh_terms: D000328:Adult; D001919:Bradycardia / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D003716:Dengue Virus / Q000472:pathogenicity / Q000502:physiology; D019468:Disease Management; D015942:Factor VIIa / Q000008:administration & dosage; D005260:Female; D005334:Fever / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D005440:Fluid Therapy; D006321:Heart / Q000503:physiopathology / Q000821:virology; D006327:Heart Block / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D006470:Hemorrhage / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D019595:Severe Dengue / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy
chemical_list: D015942:Factor VIIa