tropical cardiology

US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb

• 41 y/o Kenyan Male with 3d hx/o wheezing,

low intensity cough and marked orthopnea

• (-) hx/o asthma

• (-) hx/o valvular heart disease

• ETOH 4 beers/wk

• (-) hx/o parasitic infection, fever, or jxt

aches/skin rashes

• 41 y/o Kenyan Male with 3d hx/o wheezing,

low intensity cough and marked orthopnea

• (-) hx/o asthma

• (-) hx/o valvular heart disease

• ETOH 4 beers/wk

• (-) hx/o parasitic infection, fever, or jxt

aches/skin rashes

Physical ExamPhysical Exam

• B/P 150/104 P 64 RR 20

• mild wheezing diffusely

• Nml PMI

• Incr JVD (5 cm@45°), nml carotid pulse

• Soft s2, nml physiologically split

• (+) s4

• B/P 150/104 P 64 RR 20

• mild wheezing diffusely

• Nml PMI

• Incr JVD (5 cm@45°), nml carotid pulse

• Soft s2, nml physiologically split

• (+) s4

EKGEKG

• NSR

• LVH with QRS widening and ST segment strain

• Abnormal EKG- No comparison EKG available

• NSR

• LVH with QRS widening and ST segment strain

• Abnormal EKG- No comparison EKG available

Tropical CardiologyTropical Cardiology

Frank Meissner, MD, FACP, FACC, FCCPFrank Meissner, MD, FACP, FACC, FCCP

Nutritional Cardiac DiseasesNutritional Cardiac Diseases

Protein-Calorie Malnultrition Protein-Calorie Malnultrition

• Vacuolar degeneration of myofibrils

• Esp in conducting tissue

• Sudden death common, possibly from arrythmia

• During recovery findings of CHF often seen

• Malnourished children sensitive to digoxin, use diuretic only

• Vacuolar degeneration of myofibrils

• Esp in conducting tissue

• Sudden death common, possibly from arrythmia

• During recovery findings of CHF often seen

• Malnourished children sensitive to digoxin, use diuretic only

Beriberi Heart DiseaseBeriberi Heart Disease

• Thiamine deficiency 2° ingesting highly milled rice as staple food

• Also occurs in chronic alcoholism

• Peripheral vasodilatation - high output state

• Reduced renal blood flow with retention of Na+ & water

• Increased blood volume & biventricular failure

• Thiamine deficiency 2° ingesting highly milled rice as staple food

• Also occurs in chronic alcoholism

• Peripheral vasodilatation - high output state

• Reduced renal blood flow with retention of Na+ & water

• Increased blood volume & biventricular failure

Beriberi - diagnostic criteriaBeriberi - diagnostic criteria

• Hx/O Thiamine Deficiency

• Exclusion of other causes of heart disease

• High output failure

• Evidence of peripheral neuritis or pellagra

• Rapid response to therapeutic trial of

Thiamine

• Hx/O Thiamine Deficiency

• Exclusion of other causes of heart disease

• High output failure

• Evidence of peripheral neuritis or pellagra

• Rapid response to therapeutic trial of

Thiamine

Beriberi- treatmentBeriberi- treatment

• Thiamine hydrochloride 100 mg IV QD X 5

• Oral thiamine 50 mg qd X 1-2 weeks

• Bed rest

• ± diuretics

• Thiamine hydrochloride 100 mg IV QD X 5

• Oral thiamine 50 mg qd X 1-2 weeks

• Bed rest

• ± diuretics

Non-infectious Myocardiopathic Diseases

Idiopathic Congestive Cardiomyopathy- Epidemiology

• Worldwide distribution

• High prevalence rates among blacks in

tropical/subtropical Africa

• Nigeria - 30-40% CV disease 2° idiopathic

cardiomyopathy

• Worldwide distribution

• High prevalence rates among blacks in

tropical/subtropical Africa

• Nigeria - 30-40% CV disease 2° idiopathic

cardiomyopathy

Idiopathic Congestive Cardiomyopathy- Epidemiology

• Nigeria - 2nd most common cause of

cardiac death after RVD

• Southern Africa - 60%

• Postmortem study of East Africans - most

common fatal heart disease

• Nigeria - 2nd most common cause of

cardiac death after RVD

• Southern Africa - 60%

• Postmortem study of East Africans - most

common fatal heart disease

Idiopathic Congestive Cardiomyopathy- Etiology

• Multifactorial disease - ETOH, HTN,

Malnutrition, viral myocarditis

• West African study 40% had chronic ETOH

use + malnutrition

• Grp B Coxsackieviruses implicated if

febrile illness concurrent with CHF

• Multifactorial disease - ETOH, HTN,

Malnutrition, viral myocarditis

• West African study 40% had chronic ETOH

use + malnutrition

• Grp B Coxsackieviruses implicated if

febrile illness concurrent with CHF

Idiopathic Congestive Cardiomyopathy- Pathology

• Low output failure

• Heart grossly enlarged - 500-600 gms

• Trabeculae carneae are smoothed out

• Thrombus often seen in apical region

• Mitral/tricuspid rings dilated without evidence of intrinsic valvular disease

• Often present with 1° or more often 2° HTN

• Low output failure

• Heart grossly enlarged - 500-600 gms

• Trabeculae carneae are smoothed out

• Thrombus often seen in apical region

• Mitral/tricuspid rings dilated without evidence of intrinsic valvular disease

• Often present with 1° or more often 2° HTN

Idiopathic Congestive Cardiomyopathy-Clinical Findings

Idiopathic Congestive Cardiomyopathy-Clinical Findings• Fatigue

• Dyspnea

• Cardiomegaly

• Diffuse Cardiac Impulse

• Gallop Rhythm

• Murmurs of MR/TR

• Fatigue

• Dyspnea

• Cardiomegaly

• Diffuse Cardiac Impulse

• Gallop Rhythm

• Murmurs of MR/TR

Tropical Endomyocardial Fibrosis- Epidemiology

• Uganda, Kenya, Zambia (E. Africa);

Nigeria, Ghana, Ivory Coast (W. Africa)

• Brazil, Columbia, Venezuela, Mexico (S. & Cntrl America)

• Kerala & Haryana (India)

• Uganda, Kenya, Zambia (E. Africa);

Nigeria, Ghana, Ivory Coast (W. Africa)

• Brazil, Columbia, Venezuela, Mexico (S. & Cntrl America)

• Kerala & Haryana (India)

Tropical Endomyocardial Fibrosis- Epidemiology

• In Uganda - as common a cause of cardiac failure as RHD

• Uganda - seen in 25% of cardiac necropsies

• More common in poorer socioeconomic conditions

• In endemic areas 50% occur in persons < 15 yrs of age

• In Uganda - as common a cause of cardiac failure as RHD

• Uganda - seen in 25% of cardiac necropsies

• More common in poorer socioeconomic conditions

• In endemic areas 50% occur in persons < 15 yrs of age

Tropical Endomyocardial Fibrosis- Etiology

• Tropical environment

• Familial occurrence

• Circulating autoimmune heart antibodies

• Deposition of immune complexes in heart

• Elevated malaria antibody titers

• Tropical spleenomegaly

• Tropical environment

• Familial occurrence

• Circulating autoimmune heart antibodies

• Deposition of immune complexes in heart

• Elevated malaria antibody titers

• Tropical spleenomegaly

Tropical Endomyocardial Fibrosis- Pathology

• Fibrosis of mural endocardium

• Thrombus deposition followed by fibrotic organization

• Early in disease embolization may occur

• Usual extends to the mitral and tricuspid valve apparatus

• Fibrosis of mural endocardium

• Thrombus deposition followed by fibrotic organization

• Early in disease embolization may occur

• Usual extends to the mitral and tricuspid valve apparatus

Tropical Endomyocardial Fibrosis- Pathology

• Valvular regurgitation can often occur

• Restriction of cardiac filling/cardiac output

• R-ventricle infundibulum hypertrophied and dilated

• Severe R-sided failure symptoms can be seen (ascites/hepatomegaly)

• L-ventricular involvement results in MR & PAH

• Valvular regurgitation can often occur

• Restriction of cardiac filling/cardiac output

• R-ventricle infundibulum hypertrophied and dilated

• Severe R-sided failure symptoms can be seen (ascites/hepatomegaly)

• L-ventricular involvement results in MR & PAH

Tropical Endomyocardial Fibrosis- Clinical FindingsTropical Endomyocardial Fibrosis- Clinical Findings

• May manifest in first several months in life

• Usually recognized in advanced stages

• Symptoms advance rapidly

• Process is usually biventricular

• High venous pressure causes exopthalmos, periorbital facial edema, jaundice

• May manifest in first several months in life

• Usually recognized in advanced stages

• Symptoms advance rapidly

• Process is usually biventricular

• High venous pressure causes exopthalmos, periorbital facial edema, jaundice

• Ascites almost always seen, but peripheral edema rare

• Pericarditis present approx 40% cases - aggravates restrictive cardiomyopathy

• Peripheral cyanosis and clubbing common 2° low cardiac output

• Cachexia, protein-losing enteropathy, cardiac cirrhosis with hepatic failure - terminal events

• Ascites almost always seen, but peripheral edema rare

• Pericarditis present approx 40% cases - aggravates restrictive cardiomyopathy

• Peripheral cyanosis and clubbing common 2° low cardiac output

• Cachexia, protein-losing enteropathy, cardiac cirrhosis with hepatic failure - terminal events

• Hyperdynamic RV outflow - L upper parasternum

• Murmur of TR + R-sided S3

• Early peaking systolic MR murmur

• Late opening snap (MV) + L-sided S3 often heard

• Early peaking systolic MR murmur + opening snap unique to LV endomyocardial fibrosis

• Hyperdynamic RV outflow - L upper parasternum

• Murmur of TR + R-sided S3

• Early peaking systolic MR murmur

• Late opening snap (MV) + L-sided S3 often heard

• Early peaking systolic MR murmur + opening snap unique to LV endomyocardial fibrosis

Pericardial DiseasePericardial Disease

Acute PericarditisAcute Pericarditis• Fibrinous

– Friction rub in acute rheumatic pericarditis– Viral pericarditis - grp B coxsackie virus

• Serous– Childhood/adult pericardial TB– Endemic areas for endomyocardial fibrosis,

childhood effusion implys this Dx

• Fibrinous– Friction rub in acute rheumatic pericarditis– Viral pericarditis - grp B coxsackie virus

• Serous– Childhood/adult pericardial TB– Endemic areas for endomyocardial fibrosis,

childhood effusion implys this Dx

Acute PericarditisAcute Pericarditis• Suppurative

– Common in tropics - most commonly S. pneumoniae 2° pneumonia or S. aureus 2° osteo

– Syndrome of cough + dyspnea + toxemia + friction rub + increasing heart size

– Mortality > 35% even with prompt Dx/Rx

• Amebic Pericarditis– Rare complication of liver abscess– Rupture into pericardial sac– “Anchovy paste” pus

• Suppurative– Common in tropics - most commonly S. pneumoniae 2°

pneumonia or S. aureus 2° osteo– Syndrome of cough + dyspnea + toxemia + friction rub +

increasing heart size – Mortality > 35% even with prompt Dx/Rx

• Amebic Pericarditis– Rare complication of liver abscess– Rupture into pericardial sac– “Anchovy paste” pus

Rheumatic FeverRheumatic Fever

Rheumatic Fever - Epidemiology

• 0.05% of Strep infections lead to RF in developed world

• 0.3 - 3% Strep infections lead to RF in third world

• 0.05% of Strep infections lead to RF in developed world

• 0.3 - 3% Strep infections lead to RF in third world

Rheumatic Fever- EtiologyRheumatic Fever- Etiology

• Nonsuppurative immunologic complication of ß-hemolytic Strep

• Only URI give rise to RF, unlike, GN 2° skin or URI infections

• Nonsuppurative immunologic complication of ß-hemolytic Strep

• Only URI give rise to RF, unlike, GN 2° skin or URI infections

Rheumatic Fever- PathologyRheumatic Fever- Pathology• Endocardium, myocardium, pericardium, synovial

joint linings, lungs, or pleura• Characteristiclesion is perivascular granulomatous

reaction/vasculitis • MV involved 75-80% cases• AoV involved 30%• TV &/or PV < 5% cases• Healing complete or progressive valvular disease

over years and decades

• Endocardium, myocardium, pericardium, synovial joint linings, lungs, or pleura

• Characteristiclesion is perivascular granulomatous reaction/vasculitis

• MV involved 75-80% cases• AoV involved 30%• TV &/or PV < 5% cases• Healing complete or progressive valvular disease

over years and decades

Rheumatic Fever- Clinical Findings

• 1-4 wks post URI

• Revised Jones Criteria - 2 major or 1 major & 2 minor criteria

• 1-4 wks post URI

• Revised Jones Criteria - 2 major or 1 major & 2 minor criteria

MajorMajor

• Carditis

• Polyarthritis

• Syndenham’s chorea

• Erythema marginatum

• Subcutaneous nodules

• Carditis

• Polyarthritis

• Syndenham’s chorea

• Erythema marginatum

• Subcutaneous nodules

CarditisCarditis

• Cardiac enlargement

• Pericardial friction rub

• Mitral or aortic vavlvular diastolic murmurs

• Prolonged PR interval

• Changing quality of heart sounds

• Tachycardia out of proportion to fever

• Cardiac enlargement

• Pericardial friction rub

• Mitral or aortic vavlvular diastolic murmurs

• Prolonged PR interval

• Changing quality of heart sounds

• Tachycardia out of proportion to fever

MinorMinor• Hx/o previous RF or RVD• Fever• Polyarthralgia• Nonspecific evidence of inflammation (increased

sed rate, leukocytosis)• Prolonged P-R interval• Evidence of antecedent ß-hemolytic strp

infection, i.e., increased ASO, recent scarlet fever

• Hx/o previous RF or RVD• Fever• Polyarthralgia• Nonspecific evidence of inflammation (increased

sed rate, leukocytosis)• Prolonged P-R interval• Evidence of antecedent ß-hemolytic strp

infection, i.e., increased ASO, recent scarlet fever

Rheumatic Fever- Treatment

• Bed rest

• ASA

• Rheumatic Fever- Prognosis

• Bed rest

• ASA

• Rheumatic Fever- Prognosis

Infectious Myocardiopathic

Diseases

Infectious Myocardiopathic

Diseases

BacterialBacterial• Diphtheria

• Tuberculosis

• Typhoid Fever

• Psittacosis

• Brucellosis

• Chylamdia trachomatis

• Actinomycosis

• Diphtheria

• Tuberculosis

• Typhoid Fever

• Psittacosis

• Brucellosis

• Chylamdia trachomatis

• Actinomycosis

BacterialBacterial• Tetanus

• Tularemia

• Meliodosis

• Legionaires Disease

• Mycoplasma

• Tetanus

• Tularemia

• Meliodosis

• Legionaires Disease

• Mycoplasma

SpirochetalSpirochetal

• Syphilis

• Leptospirosis

• Relapsing Fever

• Lyme Disease

• Syphilis

• Leptospirosis

• Relapsing Fever

• Lyme Disease

RickettsialRickettsial

• Typhus

• RMSF

• Q Fever

• Typhus

• RMSF

• Q Fever

MycoticMycotic• Blastomycosis

• Candidiasis

• Aspergillosis

• Histoplasmosis

• Sporotrichosis

• Coccidoidomycosis

• Cryptococcosis

• Mucormycosis

• Blastomycosis

• Candidiasis

• Aspergillosis

• Histoplasmosis

• Sporotrichosis

• Coccidoidomycosis

• Cryptococcosis

• Mucormycosis

ProtozoalProtozoal• Chagas Disease

• African Sleeping Sickness

• Toxoplasmosis

• Malariae

• Leishmaniasis

• Balantidiasis

• Sarcosporidosis

• Amebiasis

• Chagas Disease

• African Sleeping Sickness

• Toxoplasmosis

• Malariae

• Leishmaniasis

• Balantidiasis

• Sarcosporidosis

• Amebiasis

HelminthicHelminthic

• Trichinosis

• Echinococcosis

• Schistosomiasis

• Ascariasis

• Heterophydiasis

• Trichinosis

• Echinococcosis

• Schistosomiasis

• Ascariasis

• Heterophydiasis

HelminthicHelminthic

• Filarisis

• Paragonimiasis

• Strongylodiasis

• Cysticercosis

• Visceral larva Migrans

• Filarisis

• Paragonimiasis

• Strongylodiasis

• Cysticercosis

• Visceral larva Migrans

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