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RELATIONSHIP BETWEEN MYOCARDITIS AND DENGUE
Rafael Melo Lopes1
Yana Dantas Fernandes Veras2
Janielly Zenette Alves Guedes Da Silva3
João De Sena Bernardo4
Marcos Paulo De Sena Rodrigues5
Sean De Holanda Angelim Santos6
Maria Eloisa De Castro Lima7
Raimundo Dário Coelho Campelo8
Orleâncio Gomes Ripardo de Azevedo9
Raquel Gondim Moreira10
Abstract: Introduction: Myocarditis, an inammation of the heart muscle, can arise as a complication
of dengue fever, a mosquito-borne disease. It is essential to adopt a multidisciplinary approach to moni-
tor and treat cardiac complications in patients with dengue fever at an early stage. Diagnostic tests inclu-
1 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
2 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
3 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
4 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
5 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
6 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
7 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
8 Undergraduate in Medicine from Estácio Idomed College in Canindé -Ce
9 Graduated in Biological Sciences from the State University of Ceará in the Bachelor’s and Li-
centiate degrees (2003 -2007). Master’s degree in Pharmacology from the Federal University of Ceará
(2009-2010), PhD in Pharmacology from the Federal University of Ceará 2010 - 2012 and Post-Doc-
torate from the Federal University of Ceará (2016-2021).
10 Doctor graduated from the Federal University of Ceará, Cardiologist from the Hospital de
Messejana, Responsible for the valvulopathy outpatient clinic and preoperative cardiac and non-car-
diac surgery at the Walter Cantídeo University Hospital; Coordinator of the Medical Clinic Residency
- Idomed Canindé
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de serology, PCR, and echocardiography. From a review study on cardiac involvement in dengue, it was
found that this complication is signicant and demands a multidisciplinary approach . Objective: The
objective of this study was to conduct a comprehensive integrative review to explore the relationship
between myocarditis and dengue fever. Methodology: Articles were searched in databases such as Pub-
Med, Google Scholar,Ministry of Health, and ScienceDirect, using search terms in both Portuguese and
English. Out of 122 articles found, 74 were selected for analysis, and 13 were included in the results.
Results: The studies examined the relationship between dengue fever and myocarditis, with a focus on
the cardiovascular manifestations of dengue fever and the prevalence of myocarditis in infected pa-
tients. Analysis of the articles revealed a signicant prevalence of myocarditis in patients with dengue,
highlighting a strong association between the two conditions. Discussion: Dengue patients frequently
present with cardiac issues such as myocarditis, necessitating early detection to prevent serious com-
plications. Effective vector control is crucial to reducing the impact of dengue. These ndings provide
direction for future research and the development of targeted therapies. Conclusion: Early identication
of cardiac complications, such as myocarditis in dengue patients, is crucial to reducing morbidity and
mortality. Ongoing research into the pathophysiological mechanisms is vital for the development of spe-
cic treatments. The study concludes that myocarditis is commonly associated with dengue, requiring
meticulous medical monitoring.
Keywords: Myocarditis; Patients; Dengue.
INTRODUCTION
Myocarditis is a condition characterized by inammation of the heart muscle. Signs and
symptoms can range from mild to severe including chest pain, shortness of breath, fatigue, palpitations,
and leg swelling. Some patients may present with fever, general malaise, and cough. In more severe
cases, cardiac arrhythmias, fainting, and signs of heart failure, such as pulmonary edema and
hepatomegaly, may occur. It is important to be aware of these symptoms, especially after viral and
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bacterial infections, given that myocarditis can be a complication of these conditions (BRAZILIAN
SOCIETY OF CARDIOLOGY, 2022).
Dengue is an arbovirus transmitted mainly to humans by the bite of the Aedes aegypti
mosquito. The dengue virus has four serotypes: DENV-1, DENV-2, DENV-3 and DENV-4, all capable
of causing infection in humans. Primary DENV infection can be asymptomatic or manifest as a mild
fever, however, in severe cases, it can lead to coagulopathy, increased vascular fragility and permeability,
a condition known as dengue hemorrhagic fever (DHF), which can progress to hypovolemic shock,
called dengue shock syndrome. ( KHAN et al, 2023)
Thus, laboratory conrmation of the diagnosis of dengue can be performed directly, through
the detection of viral components in the blood, or indirectly, through serological tests. The choice of
the appropriate test depends on the stage of the disease. During the initial febrile phase, the detection
of viral components in the circulation is highly sensitive. Viral nucleic acid in serum can be identied
by reverse transcriptase polymerase chain reaction (RT-PCR) or by detection of non-structural protein
1 (NS1) by enzyme-linked immunosorbent assay (ELISA). From the fth day of illness, serology for
IgM and IgG is indicated, also helping to differentiate between primary and secondary infection. A
high titre of antibodies to hemagglutinin is suggestive of secondary dengue infection. (KULARATNE
et al. 2022)
From a review study on cardiac involvement in dengue, it was found that this complication is
signicant and requires a multidisciplinary approach. It is essential to advance the understanding of the
pathophysiological mechanisms and the creation of treatment strategies to improve clinical outcomes
and reduce the morbidity and mortality associated with this condition (SILVA et al, 2024)
Myocarditis associated with dengue is mainly manifested by changes in heart rhythm, such
as tachycardia and bradycardia. Changes in the T wave and ST segment may also occur, as well as
ventricular dysfunctions, which are reected in the reduction of left ventricular ejection fraction. In
some cases, there may be an increase in cardiac enzymes (BRASIL, 2024) According to data from
Datasus, in 2024, in Ceará, ve dengue-related deaths are under investigation, which may be associated
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with myocarditis. This highlights the importance of closely monitoring dengue patients, especially those
who have cardiac symptoms, and perform appropriate diagnostic tests to identify and treat possible
complications early, such as myocarditis.
GOALS
The aim of this study was to conduct a comprehensive integrative review investigating the
relationship between myocarditis, an inammation of the heart muscle, and dengue fever, a mosquito-
borne viral disease. This review aims to explore the existing evidence in the scientic literature on how
dengue can trigger or exacerbate myocarditis.
METHODOLOGY
This is a bibliographic research of the integrative review type. This study used the following
guiding question: What is the relationship between Dengue and Myocarditis? In this sense, to survey
the articles in the literature, a search was carried out in the following databases: PubMed, Google
Scholar, Ministry of Health and Science Direct. The following descriptors were used in Portuguese and
English: and ‘’Dengue and Myocarditis’’ and ‘’Dengue and Myocarditis’’. The inclusion criteria for the
selection of articles were: articles published in Portuguese and English; full articles that were related
to the theme related to the integrative review; and articles published and indexed in these databases in
the last 5 years and in The Lancet Infectious Diseases. The exclusion criteria were articles that had no
relationship between myocarditis and dengue in question. Thus, 122 articles were obtained, of which 48
were excluded because they did not mention the relationship between myocarditis and dengue and only
74 were in accordance with the inclusion criteria of this study, where we used 13 articles to compose
our results.
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FINDINGS
Year Author Myocarditis Title
2023 Jadav N, Vaghela N, Verma N, Davis D, Sonani
AA, Patoliya P. Unmasking the Hidden Threat
of Cardiac Involvement in Dengue Fever: A
Critical Longitudinal Study. Cureus. 2023 Sep
25;15(9):e45961. doi: 10.7759/cureus.45961.
PMID: 37900359; PMCID: PMC10600330.
Present
Unmasking the Hidden Threat of
Cardiac Involvement in Dengue Fever:
A Critical Longitudinal Study
2023 Sandeep M, Padhi BK, Yella SST, Sruthi
KG, Venkatesan RG, Krishna Sasanka
KBS, Satapathy P, Mohanty A, Al-Tawq
JA, Iqhrammullah M, Rabaan AA, Kabi A,
Sah S, Rustagi S, Al-Qaim ZH, Barboza JJ,
Waheed Y, Harapan H, Sah R. Myocarditis
manifestations in dengue cases: A systematic
review and meta-analysis. J Infect Public
Health. 2023 Nov;16(11):1761-1768. doi:
10.1016/j.jiph.2023.08.005. Epub 2023 Aug 14.
PMID: 37738692.
Present
Myocarditis manifestations in dengue
cases: A systematic review and meta-
analysis.
2020 Bhatt M, Soneja M, Farooqui FA, Singla
P, Vikram NK, Biswas A, Roy A, Wig N.
Myocarditis in admitted patients with dengue
fever. Infection. 2020 Dec;48(6):899-903. doi:
10.1007/s15010-020-01500-w. Epub 2020 Aug
11. PMID: 32780310.
Present
Myocarditis in admitted patients with
dengue fever
2022 Rahim A, Hameed A, Ishaq U, Malik J,
Zaidi SMJ, Khurshid H, Malik A, Satti DI,
Naz H. Cardiovascular sequelae of dengue
fever: a systematic review. Expert Rev
Cardiovasc Ther. 2022 Jun;20(6):465-479. doi:
10.1080/14779072.2022.2082945. Epub 2022
Jun 2. PMID: 35612830.
Present
Cardiovascular sequelae of dengue
fever: a systematic review
2022 Nerella S, Sarkar UK, Namdeo H.
Electrocardiographic and echocardiographic
ndings in children with dengue infection. J
Family Med Prim Care. 2022 Jun;11(6):2334-
2339. doi: 10.4103/jfmpc.jfmpc_1280_21.
Epub 2022 Jun 30. PMID: 36119231; PMCID:
PMC9480629.
Present
Electrocardiographic and
echocardiographic ndings in children
with dengue infection
2021 Cabrera-Rego JO, Rojas-Quiroz AF,
Vidal-Turruelles Y, Yanes-Quintana AA.
Cardiovascular disorders in hospitalized
patients with dengue infection. Enferm
Infecc Microbiol Clin (Engl Ed). 2021
Mar;39(3):115-118. English, Spanish. doi:
10.1016/j.eimc.2020.02.032. Epub 2020
Apr 25. PMID: 32345488.
Presente
Cardiovascular disorders in
hospitalized patients with dengue
infection
2022 Gupta S, Gupta M, Kashyap JR,
Arora SK. Early cardiovascular
involvement in dengue fever: A
prospective study with two-dimensional
speckle tracking echocardiography.
Tropical Doctor. 2022;52(2):285-292.
doi:10.1177/00494755221076686
Presente
Early cardiovascular involvement in
dengue fever: A prospective study
with two-dimensional speckle tracking
echocardiography
2021 Shah C, Vijayaraghavan G, Kartha CC.
Spectrum of cardiac involvement in
patients with dengue fever. Int J Cardiol.
2021 Feb 1;324:180-185. doi: 10.1016/j.
ijcard.2020.09.034. Epub 2020 Sep 13.
PMID: 32931859.
Presente
Spectrum of cardiac involvement
in patients with dengue fever. Int J
Cardiol.
2019 Buntubatu S, Prawirohartono EP, Arguni
E. Myocarditis Prevalence in Paediatric
Dengue Infection: A Prospective Study
in Tertiary Hospital in Yogyakarta,
Indonesia. J Trop Pediatr. 2019 Dec
1;65(6):603-608. doi: 10.1093/tropej/
fmz020. PMID: 31006000.
Presente
Myocarditis Prevalence in Paediatric
Dengue Infection: A Prospective Study
in Tertiary Hospital in Yogyakarta,
Indonesia
2019 Manish Soneja, Manasvini Bhatt, Faraz
A Farooqui, Naval K Vikram, Ashutosh
Biswas, Ambuj Roy, Naveet Wig, 2654.
Myocarditis in Dengue: A Prospective
Observational Study, Open Forum
Infectious Diseases, Volume 6, Issue
Supplement_2, October 2019, Pages
S928–S929, https://doi.org/10.1093/od/
ofz360.2332
Presente
Myocarditis in Dengue: A Prospective
Observational Study
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2021 Cabrera-Rego JO, Rojas-Quiroz AF,
Vidal-Turruelles Y, Yanes-Quintana AA.
Cardiovascular disorders in hospitalized
patients with dengue infection. Enferm
Infecc Microbiol Clin (Engl Ed). 2021
Mar;39(3):115-118. English, Spanish. doi:
10.1016/j.eimc.2020.02.032. Epub 2020
Apr 25. PMID: 32345488.
Presente
Cardiovascular disorders in
hospitalized patients with dengue
infection
2022 Gupta S, Gupta M, Kashyap JR,
Arora SK. Early cardiovascular
involvement in dengue fever: A
prospective study with two-dimensional
speckle tracking echocardiography.
Tropical Doctor. 2022;52(2):285-292.
doi:10.1177/00494755221076686
Presente
Early cardiovascular involvement in
dengue fever: A prospective study
with two-dimensional speckle tracking
echocardiography
2021 Shah C, Vijayaraghavan G, Kartha CC.
Spectrum of cardiac involvement in
patients with dengue fever. Int J Cardiol.
2021 Feb 1;324:180-185. doi: 10.1016/j.
ijcard.2020.09.034. Epub 2020 Sep 13.
PMID: 32931859.
Presente
Spectrum of cardiac involvement
in patients with dengue fever. Int J
Cardiol.
2019 Buntubatu S, Prawirohartono EP, Arguni
E. Myocarditis Prevalence in Paediatric
Dengue Infection: A Prospective Study
in Tertiary Hospital in Yogyakarta,
Indonesia. J Trop Pediatr. 2019 Dec
1;65(6):603-608. doi: 10.1093/tropej/
fmz020. PMID: 31006000.
Presente
Myocarditis Prevalence in Paediatric
Dengue Infection: A Prospective Study
in Tertiary Hospital in Yogyakarta,
Indonesia
2019 Manish Soneja, Manasvini Bhatt, Faraz
A Farooqui, Naval K Vikram, Ashutosh
Biswas, Ambuj Roy, Naveet Wig, 2654.
Myocarditis in Dengue: A Prospective
Observational Study, Open Forum
Infectious Diseases, Volume 6, Issue
Supplement_2, October 2019, Pages
S928–S929, https://doi.org/10.1093/od/
ofz360.2332
Presente
Myocarditis in Dengue: A Prospective
Observational Study
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DISCUSSION
T he a na lysi s of th e d a t a p re se nt ed i n ou r r ev iew r e vea ls t ha t t he i nvolve me nt of t he c a rd iova sc u la r
system in patients infected with dengue is not a rare occurrence. We found that anomalies detected on
scans such as ECHO or electrocardiogram (ECG), as well as elevations in serum levels of markers of
cardiac injury, can serve as risk indicators for adverse outcomes (KANGUSSU et al. 2022).
In this sense, myocarditis emerges as a common complication among dengue patients, with
an estimated prevalence of approximately 21.0% (SANDEEP et al. 2023). This association seems
to be correlated with dengue severity, suggesting a possible role of immune system activity in the
deterioration of myocardial functions. In addition, vulnerability to myocarditis seems to be higher in
children and adolescents with severe dengue, highlighting the importance of age considerations in the
clinical evaluation and management of these patients.
The origin of heart disease in dengue infection is not well understood. Several elements
contribute to its development, leading to damage to the heart muscle and consequent conduction
problems. Direct invasion of the virus into the heart muscles, immune damage caused by cytokines, or
a combination of the two can result in heart complications. Disturbances in electrolyte levels, calcium
imbalance, lactic acidosis, and ischemia due to low blood pressure are thought to play a role in the
cardiac dysfunction seen in dengue patients (BAI et al 2023; SANDEEP et al. 2023).
In addition to the clinical implications, the discussion on the epidemiology of dengue and
myocarditis highlights the urgent need for a more comprehensive evaluation. The implementation of
2022 Baqi A, Ur Rehman F, Memon PS,
Omair SF. Prevalence and Outcomes of
Myocarditis in Dengue-Infected Patients
Admitted to a Tertiary Care Hospital of
Low-Middle Income Country. Glob Heart.
2022 Jun 23;17(1):44. doi: 10.5334/gh.1129.
PMID: 35837358; PMCID: PMC9231571.
Presente
Prevalence and Outcomes of
Myocarditis in Dengue-Infected
Patients Admitted to a Tertiary Care
Hospital of Low-Middle Income
Country
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effective vector control strategies is essential to mitigate the impacts of dengue, especially in tropical
areas where re-infestation by the primary vector, Aedes aegypti, is a constant concern.
From this perspective, the studies analyzed also highlight the association between dengue
severity and the presence of cardiovascular manifestations, with almost half of the patients presenting
anomalies in ECG and ECO exams (SHAH et al. 2021). These ndings underscore the importance of
using contemporary techniques for rapid and effective diagnosis and treatment, aiming to reduce the
risks of progression to severe conditions, such as cardiogenic shock and heart failure.
In summary, the results of our study highlight the importance of surveillance and careful
monitoring of cardiovascular manifestations in patients with dengue (MANSANGUAN et al. 2021).
Early recognition of these complications is essential for effective management of the disease and for
reducing the associated risks. In addition, our ndings provide valuable insights into the pathological
mechanisms underlying cardiac involvement in dengue, paving the way for future research and
development of more targeted therapeutic strategies (SANTOS et al. 2024).
CONCLUSION
Understanding the full spectrum of cardiovascular manifestations in dengue infection is
essential for early diagnosis and appropriate management of these patients, especially in endemic areas.
This integrative review revealed that cardiac complications, including myocarditis, are not uncommon
among dengue patients. The presence of ECG abnormalities, ECHO, or elevated markers of cardiac
injury may serve as risk predictors for adverse outcomes. Early identication of these cardiovascular
signs and symptoms is crucial to reduce the morbidity and mortality associated with the disease. In
addition, our study highlights the importance of considering dengue infection as a differential diagnosis
in patients with cardiovascular presentations especially in endemic areas. Continuous research on the
pathophysiological mechanisms underlying cardiac involvement in dengue is critical for the development
of targeted therapeutic strategies and improvement of clinical practices to improve the clinical outcomes
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of these patients. Thus, it is observed that among cardiac diseases, myocarditis emerges as a condition
frequently mentioned in specialized literature concerning patients affected by dengue. This nding
highlights the importance of diligent investigation by medical professionals about potential cardiac
complications that may arise in individuals diagnosed with dengue.
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