ABC | Volume 114, Nº4, Suplement, April 2020

Case Report Athayde et al Heart Failure and Chikungunya Fever Arq Bras Cardiol 2020; 114(4Suppl.1):19-22 Discussion According to the Brazilian Guidelines on Chronic and Acute HF, 3 systematizing care for discharging patients with decompensated HF from the hospital includes resolving precipitating factors. Infections, mainly pulmonary bacterial ones, represent important causes of decompensated HF. 1 Accordingly, vaccination against pneumococcus and influenza viruses has been recommended for patients with HF. This recommendation is alignedwithUnited State´s and European guidelines, which have more temperate climates, where serious influenza virus infections are common. 3 Although these infections are also common in Brazil, it is necessary to emphasize the epidemic proportion that arboviruses have reached in diverse Brazilian states. 7 Chikungunya fever is an arboviruses transmited by an alphavirus (CHIKV). Its vectors aremosquitoes of the Aedes genus, Aedes aegypti being the main one. 10 It was first documented in Tanzania in 1952, and the first case of autochthonous transmission in Brazil was reported in 2014. 10 The name chikungunya means “crooked walk,” referring to the pronounced arthralgia caused by the disease, which is intense and at times disabling and can last for months or years. 10 Notwithstanding the recent chikungunya fever epidemic in Brazil and the high prevalence of HF, we have not found any publications citing this virus as the cause of chronic HF becoming acute. A recently published meta-analysis 6 suggests that the cardiovascular system is involved in 54.2% of cases of chikungunya fever; it is, however, necessary to emphasize that this statistic is based on reports without any standardization of the definition of this involvement, including hypotension, shock, arrhythmias, increased troponin, and even acute myocarditis. 6-8 Based on these findings, the authors suggest myocardial tropism due to CHIKV, which, like the dengue virus, parvovirus, herpes virus, and enterovirus, can cause direct damage to myocardial cells. 6 Similarly, the hemodynamic changes that are characteristic of systemic infections (such as vasodilation and tachycardia) may be sufficient for clinical decompensation to occur in patients with HF, generating hypotension and fluid leakage into extra-vascular space. In fact, when these patients are infected by CHIKV, clinical decompensationmay occur, even in the absence of myocarditis. Symptoms of chikungunya generally appear after an incubation period of one to twelve days. 11 Positivity for IgM and IgG antibodies indicates recent or current infection, given that IgM antibodies may remain positive for up to three months after the bite. The patient described had an atypical clinical progression, considering that hemodynamic decompensation occurred before the arthralgia characteristic of the fever. Nonetheless, the absence of other precipitating factors, the positive blood tests, and the clinical picture’s evolution over time (Figure 1) corroborate the hypothesis of clinical decompensation due to chikungunya fever in the present case. Unfortunately, it was not possible to perform cardiac nuclear magnetic resonance, because it was not available at our hospital. It is worth emphasizing that the exam, although useful for diagnosis myocarditis, would not have been able to confirm the hypothesis of clinical decompensation due to chikungunya fever. In addition to being difficult to diagnose, the present case was characterized by challenges in clinical management. As with other arboviruses, treatment of patients with chikungunya fever is based on adequate pain control, which is normally achieved through the use of nonsteroidal anti-inflammatory drugs (NSAID) that do not have an antiplatelet aggregation effect (such as acetylsalicylic acid). However, myocardial dysfunction counterindicated the used of NSAIDF, and, for this reason, it was necessary to opt for analgesia with opioids like tramadol. Furthermore, thrombocytopenia and active bleeding (hematuria) impeded continuation of prophylactic anticoagulation in the patient, in spite of the indication for chronic atrial fibrillation, thus increasing the risk of thromboembolic events secondary to arrhythmia. Conclusion Viral infections, especially those that are most prevalent in Brazil, such as chikungunya fever, should be considered as factors of decompensated HF in patients who were previously stable without any other clearly identified precipitating factors. Author contributions Conception and design of the research and analysis and interpretation of the data: Athayde C, Castro RRT; Acquisition of data and Writing of the manuscript: Athayde C, Nishijuka FA, Queiroz MC, Luna M, Figueiredo J, Albuquerque N, Castilho SC, Castro RRT; Critical revision of the manuscript for intellectual content: Castro RRT. 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 article is part of the medical residency conclusion work by Carolina Cunto de Athayde, from Hospital Naval Marcilio Dias. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Hospital Naval Marcilio Dias under the protocol number 02181318.1.0000.5256. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 21