Atrial Fibrillation in Dengue Infection : A Self-limiting Phenomenon ? ( Two Case Reports )

Dengue fever (DF) is highly prevalent in Indonesia as evidenced by 129,650 cases in 2015. Atrial fibrillation (AF) in dengue is exceptionally rare and usually self-limiting with resolution after recovery of illness. The aim of this case report is to depict two patients with AF in DF which resolves spontaneously in one and persists after infection in the other. Case 1 was 50 years old male presented with fever since 4 days before admission. NS1 antigen and IgM anti-Dengue virus were positive. An electrocardiogram (ECG) showed AF with rapid ventricular response (AFRVR). Case 2 was 53 years old male presented with dyspnea and palpitations 1 hour before admission. Patient had fever since 5 days before admission. Laboratory exams showed leukopenia, thrombocytopenia and positive IgM anti-Dengue virus. An electrocardiogram showed AFRVR. Intravenous fluids (normal saline), paracetamol, and digoxin were administered in both patients. They were admitted for close monitoring. Pre-discharge ECG of Case 1 showed resolution of AF. However, in Case 2, AF persists in pre-discharge ECG. In conclusion, physicians should be aware that a potentially reversible atrial fibrillation might be caused by this infection. It should be ensured that in those persisting cases, they should not be dismissed as just an ‘irreversible’ AF and progress into full-blown heart failure.


INTRODUCTION
Dengue fever (DF) is highly prevalent in Indonesia as evidenced by 129,650 cases in 2015. 1 Electrocardiographic abnormalities resulting from dengue infection are common and have been reported to be in the range of 34-75%, these includes sinus bradycardia, atrioventricular blocks, premature ventricular contractions, Sinoatrial node dysfunction and Atrial Fibrillation(AF).Atrial fibrillation in dengue is exceptionally rare and usually self-limiting with resolution after recovery of illness [2][3][4] .The aim of this case report is to depict two patients with AF in DF which resolves spontaneously in one and persists after infection in the other.explains that myocardial injury in dengue may be due to release of cytokine mediators and/or cellular components of the immune response. 5e patients with dengue hemorrhagic fever and

Case 1 :
50 years old male presented with fever since 4 days before admission.Associated symptoms were myalgia, blanching rashes on chest, and palpitation.There was no previous episode of palpitation, dyspnea, chest pain/ discomfort or syncope.Past medical history of hypertension was confirmed and he consumed amlodipine regularly.History of diabetes, cardiac, kidney or cerebral illness was denied.

Figure 1 .
Figure 1.Electrocardiography recording of first case showing atrial fibrillation with rapid ventricular response (AFRVR)

Figure 2 .
Figure 2. Chest X-Ray of first case showing no abnormalities

Figure 3 .Case 2 :
Figure 3. Pre-discharge electrocardiography recording of first case showing resolution of atrial fibrillation.

Figure 5 .
Figure 5. Chest X-Ray of second case showing no abnormalities dengue shock syndrome have higher level of TNF-α, IL-6, IL-13 and IL-18, and cytotoxic factor which cause direct infection of cardiac muscle and trigger arrhythmias.Other hypothesis is altered contractility in dengue myocarditis secondary to increased resting intracellular calcium in the viral infected cardiac myocytes. 5The diagnosis of DHF in the first patient was confirmed by evidence of fever, rashes, thrombocytopenia, leucopenia, hemoconcentration, with positive serological tests.While diagnosis of DF in the second patient was established by the presence of fever, leucopenia, thrombocytopenia and positive serological test.The possibility of AF in the first case was a consequence of DHF was established due to resolution of AF at the end of hospitalization period and the fact that patient had never experienced previous episode of palpitation, dyspnea or chest discomfort.It is less clear however, whether fever precipitated AF in the presence of hypertensive heart disease as a substrate, direct invasion or autoimmune

Figure 4 .
Figure 4. Electrocardiography recording of the second case showing atrial fibrillation with rapid ventricular response (AFRVR)