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CASE REPORT
DENGUE MYOCARDITIS
Worakan Promphan1, Somkiat Sopontammarak1, Pornpimol Pruekprasert1,
Wanchai Kajornwattanakul2 and Apichai Kongpattanayothin3
1
Department of Pediatrics, Prince of Songkla University, Songkhla; 2Department of Pediatrics,
Maharaj Hospital, Nakhon Si Thammarat; 3Department of Pediatrics, Chulalongkorn University,
Bangkok, Thailand
Abstract. We report a 13-year-old boy who developed bradycardia and hypotension a day after re-
covery from dengue hemorrhagic fever. His electrocardiogram, during the bradycardia, showed a
junctional rhythm with a rate of 50 beats/minute. This is the first reported case of sinus node dysfunc-
tion following dengue infection.
A previously healthy 13-year-old Thai boy fore lidocaine 1 mg/kg was intravenous adminis-
was referred from a private hospital because of tered, followed by a continuous infusion at 16 µg/
bradycardia. He was admitted to Nakhon-Chris- kg/minute.
tian Hospital with history of high fever for 12 He was referred to Songklanagarind Hospi-
hours without a local source of infection. Four tal on day 7 of illness. He had cold calmy skin,
days after admission, he started developing hy- fair tissue perfusion, slightly puffy eyelids, and
potension and plasma leakage, evidenced by bi- mild hepatomegaly. Cardiac auscultation revealed
lateral pleual effusions and ascites, with an en- an S3 gallop without a significant murmur. An
larged and tender liver. He recovered from shock electrocardiogram demonstrated sinus tachycar-
on day 5, after appropiate fluid management. dia, non specific ST-T change, and no PVCs (Fig
There was no bleeding diathesis and the highest 2). A CBC demonstrated a hematocrit of 32%,
hematocrit was 43%. white blood cells 8,100/mm3 (neutrophils 71%,
A complete blood count (CBC) on the day lymphocytes 18%), and platelets 39,000/mm3.
of admission revealed the following: white blood The following investigations gave normal or
cell count 5,100/mm3 (with 88% neutrophils, 10% negative results: serum urea 6.4 mmol/l, serum
lymphocytes, and 2% monocytes); hemoglobin creatinine 0.7 mmol/l, serum sodium 133 mmol/
12.3 g/dl; hematocrit 37%; platelets 12,000/mm3. l, serum potassium 3.9 mmol/l, serum chloride
Serum sodium was 137 mmol/l, potassium 3.35 102 mmol/l, serum bicarbonate 21 mmol/l, and
mmol/l, chloride 106 mmol/l, and bicarbonate blood and urine cultures were negative. A two-
19.6 mmo/l. His urinalysis result was normal. dimensional echocardiogram showed normal car-
On the 6th day of illness, he developed hy- diac structures, no valvular regurgitation, but im-
potension and bradycardia. His slowest heart rate paired left ventricular (LV) systolic function (ejec-
was 50 beats/minute in a junctional escape rhythm tion fraction 40%). Chest x-ray showed cardiome-
seen on 12-lead electrocardiography (ECG). He galy and bilateral pleural effusions. The sedimen-
was transferred to the intensive care unit for close tation rate was 30 mm/hour, total creatine phos-
monitoring. At the beginning, adrenaline was in- phokinase (CK) 486 U/l, CK-MB 18.92 U/l (nor-
fused at a rate of 0.2 µg/kg/minute. His heart rate mal < 10 U/l), CK-MB/CK was 3.89, and tropo-
increased to 80 beats/minute in a junctional nin T was 0.12 ng/ml. (level >0.1 ng/ml is con-
rhythm (Fig 1) and became hemodynamically sidered elevated) (Lauer et al, 1997) The initial
stable. Then he developed frequent episodes of dengue hemagglutination titer was >1:10,240;
premature ventricular contractions (PVCs), there- with dengue IgM 100 IU/ml (normal <40 IU/ml).
Based on World Health Organization laboratory
Correspondence: Dr Worakan Promphan, Department criteria for the diagnosis of dengue hemorrhagic
of Pediatrics, Faculty of Medicine, Prince of Songkla fever (DHF), the patient had secondary dengue
University, Songkhla, Thailand. infection or DHF (WHO, 1986).
Fig 1–The ECG showed junctional rhythm on day 6 of illness (after adrenaline infusion).
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