Advertisement
Mayo Clinic Proceedings Home

Cardiac Compromise in Zika Virus Infection

Published:February 02, 2018DOI:https://doi.org/10.1016/j.mayocp.2017.12.006
      To the Editor:
      We have read with interest the case report of Schwartzmann et al
      • Schwartzmann P.V.
      • Ramalho L.N.
      • Neder L.
      • et al.
      Zika virus meningoencephalitis in an immunocompromised patient.
      reporting a single case of Zika virus (ZIKV) meningoencephalitis, but also with ZIKV propagation to other organs, including the heart. As in other arboviral diseases (dengue and chikungunya),
      • Villamil-Gómez W.E.
      • Ramirez-Vallejo E.
      • Cardona-Ospina J.A.
      • Silvera L.A.
      • Rodríguez-Morales A.J.
      Electrocardiographic alterations in patients with chikungunya fever from Sucre, Colombia: a 42-case series.
      • Hidalgo-Zambrano D.M.
      • Jimenez-Canizales C.E.
      • Alzate-Piedrahita J.A.
      • Medina-Gaitán D.A.
      • Rodríguez-Morales A.J.
      Electrocardiographic changes in patients with Chikungunya fever.
      • Alvarez M.F.
      • Bolívar-Mejía A.
      • Rodriguez-Morales A.J.
      • Ramirez-Vallejo E.
      Cardiovascular involvement and manifestations of systemic Chikungunya virus infection: a systematic review.
      cardiovascular disorders such as arrhythmias, among others, are being observed in previously healthy cases. But there is a lack of publications assessing it. We take this opportunity to discuss 2 cases of pregnant women from an endemic area (Sucre, Colombia), with confirmed ZIKV infection who presented with cardiovascular and electrocardiographical (ECG) alterations (myocarditis).
      Case 1. Age 30 years, 34.2 gestational weeks, presenting with rash and pruritus. Zika-RT-PCR positive, negative for dengue and chikungunya. Her ECG showed a sinusal tachycardia with a prolonged QTc (associated with Torsade de Pointes) (using Bazett formula) (Figure A). Cardiac enzymes were negative. At the echocardiogram, 200 cc of pericardial fluid was found. She had not presented with cardiovascular disease earlier. After 2 weeks, ECGs and echocardiograms were normal.
      Figure thumbnail gr1
      FigureElectrocardiographical alterations in case 1 (A) and case 2 (B).
      Case 2. Age 25 years, 10.1 gestational weeks, presenting with rash and pruritus. Zika-RT-PCR positive, negative for dengue and chikungunya. Her ECG showed a left anterior hemiblock (Figure B). At the echocardiogram, 300 cc of pericardial fluid was found. Cardiac enzymes were negative. She had not presented with cardiovascular disease earlier. After 2 weeks, ECGs and echocardiograms were normal.
      The ECG alterations were seen in patients, previously healthy and young patients, as well as also reported recently in congenital cases.
      • Cavalcanti D.D.
      • Alves L.V.
      • Furtado G.J.
      • et al.
      Echocardiographic findings in infants with presumed congenital Zika syndrome: retrospective case series study.
      Although a large epidemic of ZIKV has affected the Americas, there is a lack of literature about cardiovascular manifestations in adult patients with ZIKV infection, including those who are pregnant. This would lead to prospective systematic ECG assessments in patients with ZIKV infection.
      • Alvarez M.F.
      • Bolívar-Mejía A.
      • Rodriguez-Morales A.J.
      • Ramirez-Vallejo E.
      Cardiovascular involvement and manifestations of systemic Chikungunya virus infection: a systematic review.
      As has been recently proposed with chikungunya, in patients with suspicion of ZIKV infection, cardiovascular assessment and ECG should be routinely performed, especially in pregnant women.
      Although this case report has limitations, it would be the first in the Caribbean region of Colombia and in the country, adding evidence that ECG alterations in patients with confirmed ZIKV infection would occur. We agree with Schwartzmann et al
      • Schwartzmann P.V.
      • Ramalho L.N.
      • Neder L.
      • et al.
      Zika virus meningoencephalitis in an immunocompromised patient.
      regarding the relevance of ZIKV infection as a global public health emergency still with limited available information about ZIKV infection with neurologic and cardiovascular involvement in immunocompromised patients, including those who are pregnant. Prospective studies are necessary to establish the relative frequency of cardiovascular and ECG alterations in patients with ZIKV infection.

      References

        • Schwartzmann P.V.
        • Ramalho L.N.
        • Neder L.
        • et al.
        Zika virus meningoencephalitis in an immunocompromised patient.
        Mayo Clin Proc. 2017; 92: 460-466
        • Villamil-Gómez W.E.
        • Ramirez-Vallejo E.
        • Cardona-Ospina J.A.
        • Silvera L.A.
        • Rodríguez-Morales A.J.
        Electrocardiographic alterations in patients with chikungunya fever from Sucre, Colombia: a 42-case series.
        Travel Med Infect Dis. 2016; 14: 510-512
        • Hidalgo-Zambrano D.M.
        • Jimenez-Canizales C.E.
        • Alzate-Piedrahita J.A.
        • Medina-Gaitán D.A.
        • Rodríguez-Morales A.J.
        Electrocardiographic changes in patients with Chikungunya fever.
        Rev Panam Infectol. 2016; 18: 13-15
        • Alvarez M.F.
        • Bolívar-Mejía A.
        • Rodriguez-Morales A.J.
        • Ramirez-Vallejo E.
        Cardiovascular involvement and manifestations of systemic Chikungunya virus infection: a systematic review.
        F1000Research. 2017; 6: 390
        • Cavalcanti D.D.
        • Alves L.V.
        • Furtado G.J.
        • et al.
        Echocardiographic findings in infants with presumed congenital Zika syndrome: retrospective case series study.
        PLoS One. 2017; 12: e0175065

      Linked Article

      • Zika Virus Meningoencephalitis in an Immunocompromised Patient
        Mayo Clinic ProceedingsVol. 92Issue 3
        • Preview
          The World Health Organization considers the Zika virus (ZIKV) outbreak in the Americas a global public health emergency. The neurologic complications due to ZIKV infection comprise microcephaly, meningoencephalitis, and Guillain-Barré syndrome. We describe a fatal case of an adult patient receiving an immunosuppressive regimen following heart transplant. The patient was admitted with acute neurologic impairment and experienced progressive hemodynamic instability and mental deterioration that finally culminated in death.
        • Full-Text
        • PDF
      • In Reply–Cardiac Compromise in Zika Virus Infection
        Mayo Clinic ProceedingsVol. 93Issue 3
        • Preview
          We read with interest the letter from Villamil-Goméz et al,1 which reinforces the possibility of frequent subclinical cardiovascular involvement in Zika virus (ZIKV) infection, especially in immunocompromised patients.
        • Full-Text
        • PDF
      • Electrocardiographic Finding in Zika Virus Infection
        Mayo Clinic ProceedingsVol. 93Issue 7
        • Preview
          We read the article by Villamil-Gómez et al1 with great interest. Villamil-Gómez et al reported 2 interesting cases of Zika virus–infected patients with abnormal electrocardiographic (ECG) findings and mentioned that “there is a lack of literature about cardiovascular manifestations in adult patients with ZIKV infection.”1,p393 In fact, Zika virus infection might cause cardiac involvement and it is a possibly forgotten clinical presentation.2 Nevertheless, the effect on cardiac rhythm is extremely rare.
        • Full-Text
        • PDF