Dengue fever and takotsubo syndrome Pathophysiologic connotations + MODEL Journal of the Formosan Medical Association (2016) xx, 1e2 Available online at www sciencedirect com ScienceDirect journal hom[.]
+ MODEL Journal of the Formosan Medical Association (2016) xx, 1e2 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.jfma-online.com LETTER TO THE EDITOR Dengue fever and takotsubo syndrome: Pathophysiologic connotations To the Editor, I read with interest the contribution by Chou and Yu,1 published online ahead of print on July 18, 2016, in the Journal of the Formosan Medical Association, about a 72year-old woman who suffered takotsubo syndrome (TTS) in association with acute dengue virus infection (DVI) The authors refer to a previous similar case of TTS in association with DVI.2 Both of these cases were observed in patients with DVI, who had TTS manifesting as transient segmental left ventricular (LV) dysfunction, affecting the apical and midventricular LV territories, with sparing of the basal LV segments In addition, both these patients manifested prolonged electrocardiogram corrected QT interval (QTc) and symmetrical deep inverted T waves in the electrocardiogram (ECG).1,2 The authors also refer to 18 previously reported patients who had DVI with myocarditis characterized by global hypokinesis, with a fatal fulminant myocarditis in one of the patients.3,4 A distinction should be made (and appropriately implied by the authors) between the global myocarditis associated with DVI and the focal “myocarditis” occurring in the setting of TTS, mediated by already postulated mechanisms.1,5e7 Such “myocarditis” could be viewed as “chemical myocarditis” mediated by catecholamine toxicity,8,9 and is often seen as a comorbidity to a great variety of medical and surgical illnesses triggering TTS; accordingly, TTS in the present case can be conceptualized as being mediated by the physical/emotional stresses of DVI.1 Along with increased vascular permeability and thrombocytopenia, cerebral edema is present in patients with DVI,3 and thus the latter could be the pathogenetic link to the intense activation of the autonomic sympathetic nervous system,5 and/or outpouring of blood-borne catecholamines,6 leading to TTS Consequently, it would be informative to test Conflicts of interest: The author has no conflicts of interest relevant to this article catecholamine blood levels serially in patients with DVI, with or without TTS comorbidity The prolonged QTc and sinus bradycardia, along with Twave inversions and low-amplitude ST-segments, noted in this patient fit with late TTS clinical presentation.1,5 The very rapid recovery of the ECG features within one day noted in this case is unexpected considering that T-wave inversions and prolonged QTc are attributed to myocardial edema (MI) involving the akinetic/dyskinetic LV segments in TTS,1 and persisting beyond the time point of LV function recovery and could have been explainable by a cardiac magnetic resonance imaging not showing MI.10,11 Finally, we may be able to detect milder or atypical forms of TTS,12,13 in patients with DVI, by being proactive in implementing echocardiography serially in patients with DVI References Chou MT, Yu WL Takotsubo cardiomyopathy in a patient with dengue fever J Formos Med Assoc 2016 Sep;115(9):818e9 http://dx.doi.org/10.1016/j.jfma.2016.06.010 Badve SV, Patil S, Rathod NM, Jumrani CK Dengue fever and takotsubo cardiomyopathy J Assoc Physicians India 2015;63: 67e70 Wali JP, Biswas A, Chandra S, Malhotra A, Aggarwal P, Handa R Cardiac involvement in dengue haemorrhagic fever Int J Cardiol 1998;64:31e6 Lee CH, Teo C, Low AF Fulminant dengue myocarditis masquerading as acute myocardial infarction Int J Cardiol 2009;136:e69e71 Samuels MA The braineheart connection Circulation 2007; 116:77e84 Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al Neurohumoral features of myocardial stunning due to sudden emotional stress N Engl J Med 2005;352:539e48 Paur H, Wright PT, Sikkel MB, Tranter MH, Mansfield C, O’Gara P, et al High levels of circulating epinephrine trigger apical cardiodepression in a b2-adrenergic receptor/Gidependent manner: a new model of takotsubo cardiomyopathy Circulation 2012;126:697e706 http://dx.doi.org/10.1016/j.jfma.2016.10.009 0929-6646/Copyright ª 2016, Formosan Medical Association Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: Madias JE, Dengue fever and takotsubo syndrome: Pathophysiologic connotations, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.10.009 + MODEL Madias JE Pathophysiology of takotsubo syndrome: an adrenergic cardiac “chemical neuritis/myocarditis”? Cardiovasc Revasc Med 2014;15:50 Y-Hassan S Myocarditis and takotsubo syndrome: are they mutually exclusive? Int J Cardiol 2014;177:149e51 10 Migliore F, Zorzi A, Marra MP, Basso C, Corbetti F, De Lazzari M, et al Myocardial edema underlies dynamic Twave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction Heart Rhythm 2011; 8:1629e34 11 Perazzolo Marra M, Zorzi A, Corbetti F, De Lazzari M, Migliore F, Tona F, et al Apicobasal gradient of left ventricular myocardial edema underlies transient T-wave inversion and QT interval prolongation (Wellens’ ECG pattern) in Tako-Tsubo cardiomyopathy Heart Rhythm 2013;10:70e7 12 Madias JE Forme fruste cases of takotsubo syndrome: a hypothesis Eur J Intern Med 2014;25:e47 Letter to the Editor 13 Madias JE Why the current diagnostic criteria of takotsubo syndrome are outmoded: a proposal for new criteria Int J Cardiol 2014;174:468e70 John E Madias* Icahn School of Medicine at Mount Sinai, New York, NY, USA Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA *Corresponding author Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, USA E-mail address: madiasj@nychhc.org August 2016 Please cite this article in press as: Madias JE, Dengue fever and takotsubo syndrome: Pathophysiologic connotations, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.10.009 ... madiasj@nychhc.org August 2016 Please cite this article in press as: Madias JE, Dengue fever and takotsubo syndrome: Pathophysiologic connotations, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.10.009... Madias JE Pathophysiology of takotsubo syndrome: an adrenergic cardiac “chemical neuritis/myocarditis”? Cardiovasc Revasc Med 2014;15:50 Y-Hassan S Myocarditis and takotsubo syndrome: are they mutually... transient T-wave inversion and QT interval prolongation (Wellens’ ECG pattern) in Tako-Tsubo cardiomyopathy Heart Rhythm 2013;10:70e7 12 Madias JE Forme fruste cases of takotsubo syndrome: a hypothesis