Br Heart J: first published as 10.1136/hrt.34.8.828 on 1 August 1972. Downloaded from British Heart J'ournal, I972, 34, 828-829. Conducting tissue of the heart in kwashiorkor

B. A. Sims From the Department of , Queen's University of Belfast

The conducting tissue of the heart was examined histologically in 7 cases of kwashiorkor. Atro- phic changes were found, and in 5 cases myocytolysis was present. No cellular reaction orfibrous repair was found in relation to the areas of myocytolysis. These findings may be associated with a disturbance of atrioventricular conduction during life, perhaps accounting for some of the unexplained sudden deaths occurring in children with kwashiorkor.

There is now considerable evidence to suggest The children in the 7 cases were aged i to 3 that the heart is involved in kwashiorkor. years, showing skin changes and oedema Gopalan (I955) reported electrocardiographic characteristic of kwashiorkor in most in- abnormalities such as bradycardia, T wave stances. The commonest cause of death was changes, and a prolonged QT interval, while a respiratory . histologically there was of the cardiac Histological examination of the myocar- muscle fibres. A special study of the heart in dium shows the muscle fibres to be atrophic kwashiorkor was made by Smythe, Swane- but no degenerative change is evident. In the poel, and Campbell (I962) in which they conducting tissue the wasting of the fibres is analysed the electrocardiogram to find T wave more obvious. They contain vacuoles and are inversion and a prolonged QT interval. surrounded by interstitial oedema as shown Histological examination in 24 cases revealed in the Fig. In areas the vacuolation is exten- vacuolation of the muscle fibres and some sive when it appears that myocytolysis has http://heart.bmj.com/ oedema between the cells. They considered occurred. This change is seen in varying that these findings might account for some of the sudden deaths, and also the low cardiac output state found in kwashiorkor. This study was undertaken to exclude an abnormality FIG. There is wasting of the conducting fibres involving the conducting tissue of the heart in in the AV bundle with interstitial oedema. this condition. on September 24, 2021 by guest. Protected copyright. Material and method The clinical details and the pathological material of 7 children with kwashiorkor were supplied by the Department of Pathology, Makerere Univer- sity College, Kampala, Uganda, which made this study possible. Five cases of similar age with normal nutrition were also studied for compari- son. The atrioventricular conducting tissue was examined histologically using the technique described by Hudson (I965). Sections from the ' different parts of the conducting tissue were 14 ~ ~ studied in cases of kwashiorkor and also in cases with normal nutrition, without a knowledge of the clinical background. Later the findings of the histological examination were compared. Results The clinical, pathological, and histological abnormalities are presented in the Table. ,' NiA~ 'S t" or Received 2s November I97I. Br Heart J: first published as 10.1136/hrt.34.8.828 on 1 August 1972. Downloaded from Conducting tissue oj the heart in kwashiorkor 829

TABLE Clinical and pathological findings in cases of kwashiorkor Case Age (yr) Clinicalfindings Pathological diagnosis Histological findings No. and sex in conducting tissue I 24 M Skin rash and oedema Kwashiorkor; oedema lungs, ? viral pneumonia 2 I F Diarrhoea and vomiting; Kwashiorkor; anaemia; pneu- Myolysis in AV node anaemia; skin ulcers monia and main bundle I F Diarrhoea and vomiting; de- Kwashiorkor; pneumonia Myolysis in bundle pigmentation of skin; oedema and branches 4 24 M Oedema; heart failure Kwashiorkor; viral pneumonia; Myolysis in AV node malaria and bundle 5 3 F Diarrhoea and vomiting; oedema Kwashiorkor; pneumonia; hook- worms 6 I M Diarrhoea; wasted; depigmenta- Kwashiorkor; broncho- Myolysis in all parts tion of skin pneumonia; malaria of tissue 7 2 M Vomiting and diarrhoea; oedema; Kwashiorkor; malabsorption Myolysis in AV node palpable liver ? lactose intolerance; loss of pancreatic tissue

severity in 5 cases. In none of these cases are myocardial fibres, perhaps because the con- inflammatory cells or Anitschkow myocytes ducting fibres contain fewer myofibrils. Wen in relation to areas of myocytolysis. Also no increase in connective tissue is present in I am grateful to Professor M. S. R. Hutt and his these areas. No such changes are present in staff in the Pathology Department, Makerere the control cases with normal nutrition. University College, Kampala, Uganda, for sup- plying the clinical details and the pathological specimens. Also to Professor Sir John Biggart, C.B.E., in whose department this study was per- Discussion formed. I am also indebted to Dr. D. R. Hadden The most striking histological finding in the for his advice and encouragement, to Professor Florence McKeown for her assistance with conducting tissue in these cases of kwashior- http://heart.bmj.com/ kor is the wasting and disintegration of con- the histology, and to Mr. W. Kirkwood for the technical assistance in preparing the histological ducting fibres. The term myocytolysis is used sections. to describe the latter process which is similar to the change of myolysis described by Chauhan, Nayak, and Ramalingaswami (I965) References in protein deficient rhesus monkeys. The re- Chauhan, S., Nayak, N. C., and Ramalingaswami, V. sulting clear areas may represent interstitial (I965). The heart and skeletal muscle in experi- mental protein malnutrition in rhesus monkeys.

edema but no fibrosis has occurred. on September 24, 2021 by guest. Protected copyright. of Pathology and Wharton et al. myo- Journal Bacteriology, 90, 30I. (i969) examined the Gopalan, C. (I955). In Discussion on pathology of tardium histologically in 5 cases of kwashior- protein malnutrition. In Protein Malnutrition, kor, and in 2 found areas of patchy in p. I27. Ed. by J. C. Waterlow. University Press, the papillary muscles and subendocardially. In Cambridge. Hudson, R. E. B. (I965). Cardiovascular Pathology, i case in present the series myocytolysis is in- Vol. I, p. 66. Edward Arnold, London. volving the left bundle-branch as it lies under Smythe, P. M., Swanepoel, A., and Campbell, J. A. H. tSke endocardium, but no areas of necrosis (I962). The heart in kwashiorkor. British Medical are seen in the myocardium. Journal, I, 67. r This study has shown atrophic changes in Wharton, B. A., Balmer, S. E., Somers, K., and Templeton, A. C. (I969). The myocardium in the conducting tissue with kwashiorkor, the kwashiorkor. Quarterly Journal of Medicine, 38, functional significance of which is uncertain, I07. but they may produce a failure of atrioventri- cular conduction to cause sudden death. The Requests for reprints to Dr. B. A. Sims, Depart- siore conspicuous atrophic changes in the ment of Therapeutics and Pharmacology, Insti- conducting tissue suggest that it is more sensi- tute of Clinical Science, Grosvenor Road, Belfast, 4ve to protein deficiency than the ordinary BTI2 6BJ, Northern Ireland.