ABC | Volume 113, Nº4, October 2019

Case Report Farias et al. Myocarditis due to Chikungunya/Dengue coinfection Arq Bras Cardiol. 2019; 113(4):783-786 Table 1 – Laboratory results during hospital stay of a patient with myocarditis and coinfection with dengue virus and Chikungunya virus Characteristic Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Hemoglobin, g/dL 18.6 17.2 15.7 15.4 14.4 13.6 12.6 12.9 12.7 14.1 13.9 Hematocrit, % WBC count, x10 3 /mm 3 12.5 17.4 19.6 18 14 11.1 9.4 8.1 6 6.1 6.7 Polymorphs, % Lymphocytes, % Lymphocyte count, x10 9 /L 1.5 1.57 1.76 1.26 1.4 1.78 1.22 1.37 1.45 1.83 2.29 Platelet count, x10 9 /l 135 122 158 177 182 169 160 156 164 199 207 Creatinine level, mg/dL 1.51 1.65 1.52 1.69 1.42 1.32 1.23 1.29 1.04 1.02 1.23 CRP levels, mg/dl 0.89 0.99 0.45 0.35 0.25 0.43 0.53 0.52 0.31 0.21 0.14 Serum Lactate level mmol/l 11.4 4.5 2.4 NT-proBNP, pg/mL 32692 20858 14543 13832 LDH, IU/L 522 1371 360 ESR, mm 3 2 CK level, U/L 1306 347 Troponin I, ng/mL 1.05 0.5 0.47 INR 1.56 1.73 1.51 1.26 1.19 1.14 1.12 WBC: White Blood Cell; CRP: C - Reactive Protein; NT-proBNP: N-Terminal Pro-Brain Natriuretic Peptide; LDH: Lactate Dehydrogenase; ESR: Erythrocyte Sedimentation Rate; CK level: Creatine Kinase level; INR: International Normalized Ratio. loss and cardiogenic shock is still the most recommended management. 6 There is also evidence that IV hydrocortisone may be helpful to accomplish full recovery in DENV myocarditis 18 but there is yet no consensus about whether this drug should be used in this setting or if it has a real impact on recovery and mortality rates, even more in cases of combined arbovirus infection. Although arbovirus myocarditis is an acute condition, most patients persist chronically with cardiac disease, such as chronic heart failure and ECG T-wave changes. 16,19 The role of coinfection in the severity of arbovirus cardiac manifestations is not currently known, but studies regarding other symptoms showed that it might contribute to a more severe disease. 6,7,20 It is also noteworthy that the herein described myocarditis may have been caused solely by the CHIKV, since the NS1 protein test yielded a negative result. It is also important to note that the DENV IgM may be positive from 139 up to 179 days, respectively for secondary and primary infections. 21 The present study has limitations. Polymerase chain reaction (PCR) was not available for the etiological diagnosis. The degree of myocardial impairment was not assessed by Magnetic Resonance Imaging (MRI). Although reported by other authors, 8,9 MRI was not available at our center. Conclusion The case presented herein suggests that DENV and CHIKV coinfection may result in myocarditis, which can be severe and may be possibly reverted with supportive therapy and correct management of cardiac function. Nevertheless, the correct etiopathogenesis of the cardiac disorder is undefined and the disease may be caused solely by either the DENV or CHIKV virus. It is important to be aware of this possible complication of arboviruses mainly in endemic areas. Author contributions Conception and design of the research: Farias LABG, Beserra FLCN, Fernandes L, Teixeira AAR, Girão ES, Pires Neto RJ; Acquisition of data: Farias LABG, Beserra FLCN, Fernandes L, Teixeira AAR, Ferragut JM, Pires Neto RJ; Analysis and interpretation of the data: Ferragut JM, Girão ES, Pires Neto RJ; Statistical analysis: Pires Neto RJ; Writing of the manuscript: Farias LABG, Beserra FLCN, Fernandes L, Teixeira AAR, Pires Neto RJ; Critical revision of the manuscript for intellectual content: Ferragut JM, Girão ES, Pires Neto RJ. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Hospital de São José de Doenças Infecciosas under the protocol number 2.405.527. All the procedures in this study were in accordancewith the 1975Helsinki Declaration, updated in 2013. 785