Chest discomfort in a patient with dengue: is it an acute MI
Published in the journal of Malaysian Family Physician, the authors describe a case of dengue myocarditis mimicking an acute myocardial infarction in a 56-year-old woman.

A 56-year-old woman, presented with complaints of chest discomfort, progressive shortness of breath, leg swelling, abdominal fullness, and decreased effort tolerance for one day.

There was an absence of chest pain and profuse sweating. Six days prior to the onset of these symptoms, she had presented with a high-grade fever at a private hospital and been diagnosed with dengue fever (positive NS1 antigen). She was hospitalized and, following an uneventful stay, allowed to return home after six days.

Her jugular venous pulse was raised, and there was bilateral pedal oedema. Precordial examination was unremarkable but crepitations were audible at the lung bases. An ECG revealed sinus tachycardia with a rate of approximately 100/ min; saddle-shaped ST-segment elevation greater than 2mm in leads II, aVF, V4, V5, and V6 without reciprocal ST depression, and diminished QRS amplitude in several limb and chest leads.

A chest radiograph confirmed the presence of minimal bilateral pleural effusion. Echocardiography revealed minimal pericardial effusion with no evidence of cardiac tamponade and an ejection fraction of 60%.

The chambers sizes were normal with no hypokinetic areas. Her troponin I level was elevated (10.51 ng/ml; reference < 0.04 ng/ml) along with the other cardiac markers. A clinical diagnosis of dengue myocarditis with acute left heart failure was made. She was administered supplemental oxygen and an intravenous diuretic (furosemide) and advised to have complete bed rest.

Serial ECGs done up to 12 hours post-admission revealed similar ST-segment elevations with no Q wave formation. Serial aspartate transaminase (AST) demonstrated a downward trend to normalization by day 7 of hospitalization. She was discharged after 12 days of uneventful hospitalization with the advice to avoid strenuous exercise till her next review at the outpatient clinic.

Learning points:-
• Although the ECG changes and raised troponin I level in our patient were in favor of AMI, the preceding history of a viral infection and absence of chest pain and profuse sweating prompted consideration of the alternative diagnosis of dengue myocarditis.

• The lack of Q-wave formation in serial ECGs in this patient provided another vital clue that she did not suffer an AMI.

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