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Dated but relevant discussion of Tropical Diseases and their cardiac manifestations.
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US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
HxHx
• 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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical CardiologyTropical Cardiology
Frank Meissner, MD, FACP, FACC, FCCPFrank Meissner, MD, FACP, FACC, FCCP
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Nutritional Cardiac DiseasesNutritional Cardiac Diseases
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Beriberi- treatmentBeriberi- treatment
• Thiamine hydrochloride 100 mg IV QD X 5
days
• Oral thiamine 50 mg qd X 1-2 weeks
• Bed rest
• ± diuretics
• Thiamine hydrochloride 100 mg IV QD X 5
days
• Oral thiamine 50 mg qd X 1-2 weeks
• Bed rest
• ± diuretics
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Non-infectious Myocardiopathic Diseases
Non-infectious Myocardiopathic Diseases
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive Cardiomyopathy- Epidemiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive Cardiomyopathy- Epidemiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive Cardiomyopathy- Etiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive Cardiomyopathy- Pathology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Epidemiology
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)
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Epidemiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Etiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Pathology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Pathology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Clinical FindingsTropical Endomyocardial Fibrosis- Clinical Findings
• 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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial Fibrosis- Clinical FindingsTropical Endomyocardial Fibrosis- Clinical Findings
• 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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Pericardial DiseasePericardial Disease
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic FeverRheumatic Fever
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever - Epidemiology
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever- Clinical Findings
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
MajorMajor
• Carditis
• Polyarthritis
• Syndenham’s chorea
• Erythema marginatum
• Subcutaneous nodules
• Carditis
• Polyarthritis
• Syndenham’s chorea
• Erythema marginatum
• Subcutaneous nodules
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
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
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever- Treatment
Rheumatic Fever- Treatment
• Bed rest
• ASA
• Rheumatic Fever- Prognosis
• Bed rest
• ASA
• Rheumatic Fever- Prognosis
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Infectious Myocardiopathic
Diseases
Infectious Myocardiopathic
Diseases
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
BacterialBacterial• Diphtheria
• Tuberculosis
• Typhoid Fever
• Psittacosis
• Brucellosis
• Chylamdia trachomatis
• Actinomycosis
• Diphtheria
• Tuberculosis
• Typhoid Fever
• Psittacosis
• Brucellosis
• Chylamdia trachomatis
• Actinomycosis
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
BacterialBacterial• Tetanus
• Tularemia
• Meliodosis
• Legionaires Disease
• Mycoplasma
• Tetanus
• Tularemia
• Meliodosis
• Legionaires Disease
• Mycoplasma
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
SpirochetalSpirochetal
• Syphilis
• Leptospirosis
• Relapsing Fever
• Lyme Disease
• Syphilis
• Leptospirosis
• Relapsing Fever
• Lyme Disease
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
RickettsialRickettsial
• Typhus
• RMSF
• Q Fever
• Typhus
• RMSF
• Q Fever
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
MycoticMycotic• Blastomycosis
• Candidiasis
• Aspergillosis
• Histoplasmosis
• Sporotrichosis
• Coccidoidomycosis
• Cryptococcosis
• Mucormycosis
• Blastomycosis
• Candidiasis
• Aspergillosis
• Histoplasmosis
• Sporotrichosis
• Coccidoidomycosis
• Cryptococcosis
• Mucormycosis
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
ProtozoalProtozoal• Chagas Disease
• African Sleeping Sickness
• Toxoplasmosis
• Malariae
• Leishmaniasis
• Balantidiasis
• Sarcosporidosis
• Amebiasis
• Chagas Disease
• African Sleeping Sickness
• Toxoplasmosis
• Malariae
• Leishmaniasis
• Balantidiasis
• Sarcosporidosis
• Amebiasis
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
HelminthicHelminthic
• Trichinosis
• Echinococcosis
• Schistosomiasis
• Ascariasis
• Heterophydiasis
• Trichinosis
• Echinococcosis
• Schistosomiasis
• Ascariasis
• Heterophydiasis
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
HelminthicHelminthic
• Filarisis
• Paragonimiasis
• Strongylodiasis
• Cysticercosis
• Visceral larva Migrans
• Filarisis
• Paragonimiasis
• Strongylodiasis
• Cysticercosis
• Visceral larva Migrans
US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
HIV - A completely Seperate Lecture!!!!!!
HIV - A completely Seperate Lecture!!!!!!