Postgrad Med J: first published as 10.1136/pgmj.57.665.199 on 1 March 1981. Downloaded from Postgraduate Medical Journal (March 1981) 57, 199-201

Varicella producing congestive F. T. THANDROYEN A. C. ASMAL M.R.C.P. M.R.C.P., M.D. T. G. ARMSTRONG M.D., F.R.C.P. King Edward VIII Hospital, and the Cardiac Unit, Department ofMedicine, University ofNatal Medical School, Durban, South Africa

Summary audible cardiac murmurs and the chest radiograph A 14-year-old boy with proved varicella developed showed a normal-sized heart (Fig. 1). However, severe, intractable with the clinical 4 days later he developed orthopnoea and paroxys- features of congestive cardiomyopathy. Detailed mal nocturnal dyspnoea with the clinical features of investigations failed to disclose any alternative congestive cardiac failure. Despite therapy with aetiological factor. It is proposed that varicella myo- digoxin 0.25 mg and frusemide 120 mg, both twice was the cause of the acute congestive cardio- daily, his condition failed to improve and he was Protected by copyright. myopathy found in this patient. referred to King Edward Hospital, Durban. On admission the general examination revealed Introduction the typical rash of varicella. There was pitting Although cardiac involvement in varicella has oedema of both legs and on cardiovascular examina- been described at post-mortem in those dying from tion, the pulse rate was 120 beats/min and the BP unrecognized myocarditis or from other varicella was 100/80 mmHg. The jugular venous pressure was complications (Hackel, 1953; Tatter et al., 1964; elevated 10 cm above the manubrium sterni, and it Moore et al., 1969; Morales, Adelman and Fine, exhibited the characteristic cV waves of tricuspid 1971), clinical evidence of heart involvement in this incompetence. The apex beat was hypodynamic in disease is extremely rare, and is usually only recog- character and was displaced to the 6th intercostal nized when there are suggestive electrocardiographic space in the anterior axillary line. On auscultation, changes or when cardiac failure supervenes (Vazifdar the murmurs of mitral and tricuspid incompetence de and Levine, 1952; Medeiros Neto, de Almeida and were heard, and at the cardiac apex there was a loud http://pmj.bmj.com/ Facchini, 1961). In patients who survive there are third heart sound. Bilateral basal crepitations were no reported long-term sequelae. also noted. The liver was tender, pulsatile and In this report the authors describe the develop- enlarged 10.5 cm below the costal' margin. No ment of intractable cardiac failure and acute con- additional abnormalities were detected in any of the gestive cardiomyopathy in a 14-year-old boy who other systems. was initially treated in hospital for acute varicella. The posterior-anterior (Fig. 2) and lateral chest It is proposed that the cardiomyopathy resulted X-rays demonstrated biventricular and biatrial en-

from severe varicella myocarditis. largement, pulmonary venous congestion and on September 28, 2021 by guest. distended superior vena cava. Case report The ECG showed sinus 120/min, a A 14-year-old boy was admitted to an outlying frontal QRS axis of 45°, right , hospital with severe varicella, but without any sign flat T waves in praecordial leads V4-6 and left of the potentially fatal complications, namely by voltage criteria. pneumonia, meningo-encephalitis or thrombocyto- Laboratory investigations showed a haemoglobin penic purpura. On admission there was also no concentration of 14 g/dl, a WBC of 6x 109/1 and evidence of cardiac involvement; specifically the an ESR of 112 mm/hr. Serum lactate dehydrogenase patient was not in cardiac failure, there were no was 380 i.u./l (normal values 170-340 i.u./l) and aspartate transaminase was 24 i.u./l (normal values Address for reprints: Dr F. T. Thandroyen, MRC Ischae- mic Heart Disease Research Unit, Department of Medicine, 3-12 i.u./l). Serum urea and complement were University of Cape Town Medical School, Observatory normal as was the urine analysis. Antistreptolysin 7925, South Africa. titres done on 3 occasions over a period of 3 weeks 0032-5473/81/0300-0199 $02.00 ( 1981 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.57.665.199 on 1 March 1981. Downloaded from 200 Case reports

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FIG. 1. Posterior anterior chest X-ray showing-a normal cardiothoracic ratio. http://pmj.bmj.com/ on September 28, 2021 by guest.

FIG. 2. Posterior anterior chest X-ray demonstrating marked , pulmonary venous congestion and a distended superior vena cava. Postgrad Med J: first published as 10.1136/pgmj.57.665.199 on 1 March 1981. Downloaded from Case reports 201 were normal and a throat swab failed to reveal any carditis progression towards cardiac enlargement pathogenic organisms. The varicella complement and/or dysfunction has been noted (Sainani, fixation test showed a rising titre from 1/32 to 1/128 Krompstie and Slodki, 1968; Smith, 1970; Levi over a period of 2 weeks, indicating active varicella et al., 1977), the authors believe that this is the infection. Sera did not reveal positive or rising first reported case of acute congestive cardiomyo- titres to adenovirus, Coxsackie virus or influenza pathy complicating acute viral myocarditis. Further- virus. more, they document the first described case of The patient was treated with strict bed rest, di- varicella cardiomyopathy. goxin 0-25 mg daily, together with high dose oral and Another interesting facet to this case was the i.v. frusemide. As there was no resolution of heart mode of presentation and its relationship to the failure, hydrallazine 300 mg daily and isosorbide clinical diagnosis. It is a feature of African medicine dinitrate 40 mg daily were added but were without that patients frequently present to hospital at a late effect. Four months later the patient, still in cardiac stage of their illness. Had this patient not been failure albeit less, was discharged to an outlying admitted initially, and had he first presented when hospital. On re-examination after a further 3 months, the acute varicella infection had subsided, it is likely cardiac failure was still clinically evident. that a diagnosis of idiopathic congestive cardio- myopathy would have been made; a diagnosis com- Discussion patible with the clinical findings and one common In this patient, varicella was clinically diagnosed in the African population. This highlights one on the basis of the characteristic rash with its typical difficulty in elucidating the aetiological factors distribution, and was confirmed by the rising causing congestive cardiomyopathy. varicella antibody titre. In conclusion, this case is of interest because it On admission to hospital there was no evidence of demonstrates that, although viral infections usually Protected by copyright. heart involvement and the course of the disease was run a benign course, the tendency to myocardial unremarkable until congestive cardiac failure de- involvement is always present and a rare complica- veloped. There was no previous history of rheu- tion may be the development of congestive cardio- matic fever or cardiomegaly and the clinical features myopathy. and laboratory investigations were not in keeping with acute rheumatic pancarditis or infective endo- Acknowledgments carditis. The authors attribute the auscultatory The authors are extremely grateful to Dr Timothy Noakes findings of mitral and tricuspid incompetence to for criticism of the manuscript. functional dilatation of the atrio-ventricular valves secondary to severe myocardial damage; however, References they cannot exclude direct viral involvement of the BURCH, G.E. & COLCOLOUGH, H.L. (1969) Viral valvulitis. valves as suggested to occur in other forms of viral American Heart Journal, 78, 119. myocarditis (Burch and Colcolough, 1969). The CASTLEMAN, B. & KIBBEE, B.U. (1963) Case records of the Massachusetts General Hospital. Case 15 - 1963. New http://pmj.bmj.com/ primary diagnosis was therefore varicella myo- England Journal of Medicine, 268, 488. carditis causing severe cardiac failure. DE MEDEIRos NETO, G.A., DE ALMEIDA, D.B. & FACCHINI, Hackel F.B. (1961) Myocarditis associated with chickenpox Varicella myocarditis was first reported by treated by corticosteroids. Revista do Hospitail das Clinicas in 1953 who described the post-mortem findings in Faculdade de Medicina da Universidade de Sdo Paulo, 7 children dying from severe complications of 16, 427. varicella but in none of these children had myo- HACKEL, D.B. (1953) Myocarditis in association with varicella. American Journal of Pathology, 29, 369. carditis been suspected clinically. LEVI, G.F., PROTS, C., QUADRI, A. & RATTI, S. (1977) More recent reports have shown that varicella Coxsackie virus heart disease and cardiomyopathy. on September 28, 2021 by guest. myocarditis may indeed be symptomatic. Moore American Heart Journal, 93, 419. et al (1969) described varicella myocarditis pre- MOORE, C.M., HENRY, J., BENZING, G. & KAPLAN, S. (1969) as cardiac failure in 2 children under 3 years Varicella myocarditis. American Journal of Diseases of senting Children, 118, 899. of age. Both cases responded to conventional MORALES, A.R., ADELMAN, S. & FINE, G. (1971) Varicella therapy, including steroids in one case, with com- myocarditis. Archives of Pathology, 91, 29. plete resolution of heart failure. Castleman and SAINANI, G.S., KROMPSTIE, E. & SLODKI, S.J. (1968) Adult Kibbee described a further case of heart heart disease due to the Coxsackie B infection. Medicine, (1963) 47, 133. failure in a 30-year-old woman but varicella myo- SMITH, W.G. (1970) Coxsackie B in adults. carditis was not solely responsible for the heart American Heart Journal, 80, 34. failure, because at post-mortem old fibrotic myo- TATTER, D., GERARD, P.W., SILVERMAN, A.H., WANG, C.l. & carditis together with multiple pulmonary emboli PEARSON, H.E. (1964) Fatal varicella pancarditis in a child. American Journal of Diseases of Children, 108, 88. and pulmonary infarction were also found. VAZIFDAR, J.P. & LEVINE, S.A. (1952) Benign bundle branch Although in several cases of acute viral myo- block. Archives ofInternal Medicine, 89, 568.