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Acute myocardial infarction following scrub typhus infection
International Journal of Cardiology 114 (2007) e18 – e20 www.elsevier.com/locate/ijcard
Letter to the Editor
Acute myocardial infarction following scrub typhus infection Dae Gyeun Kim a , Jin Won Kim b,⁎, Yoon Sun Choi a,⁎, Su Hyun Kim a , Seon Mee Kim a , Chang Gyu Park b , Hong Seog Seo b , Dong Joo Oh b a
Department of Family Medicine, Korea University Guro Hospital, 97 Guro-dong Gil, Guro-Gu, 152-703, South Korea b Cardiovascular Center, Korea University Guro Hospital, 97 Guro-dong Gil, Guro-gu, Seoul 152-703, South Korea Received 3 May 2006; accepted 22 July 2006 Available online 19 October 2006
Abstract Up to recently, a few cases of myocarditis in the cardiac manifestations of scrub typhus have been reported. However, acute myocardial infarction (AMI) associated with scrub typhus has not been previously reported. We presented a case of AMI ensued on scrub typhus, which were successfully treated by percutaneous coronary intervention (PCI). © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Scrup typhus; Acute myocardial infarction
1. Case A 58 year old man was admitted with febrile illness and generalized myalgia, which developed 7 days prior to admission. He was a 30 pack-year smoker without other risk factors and previous history of cardiovascular disease. On physical examination, a 13 * 11 mm-sized black-crusted shallow ulcer (eschar) was found on the medial aspect of right thigh. Laboratory data showed white blood cell count of 12,000/μL, total cholesterol 144 mg/dL and C-reactive protein 108.0 mg/dL. Serologic test for O. tsutsugamushi using indirect immunofluorescent assay antibody (IgM) was strong positive. Electrocardiography (ECG) showed normal sinus rhythm without any evidence of ischemic change. After 7 days oral doxycycline (200 mg per day) therapy, he was discharged free of previous symptoms. On 1 week after discharge, he was referred to our emergency room with squeezing chest pain lasting 3 h. On arrival, ECG showed ST elevation in V2, 3 with symmetric T ⁎ Corresponding authors. Kim is to be contacted at Tel.: +82 2 818 6851; fax: +82 2 818 6411. Choi, Tel.: +82 2 818 6886; fax: +82 2 837 3966. E-mail addresses: [email protected] (J.W. Kim), [email protected] (Y.S. Choi). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.07.131
inversion in V2-6 and I, aVL lead (Fig. 1). The levels of CKMB and troponin T were 24.7 and 0.117 ng/ml, respectively. Emergent coronary angiography showed a subtotal stenosis with TIMI 1–2 distal flow in the middle portion of left circumflex coronary artery (LCX) and a critical stenosis with TIMI 2–3 flow in the first diagonal branch (Fig. 2). We successfully performed stenting with a 2.75 * 23 mm Cypher™ stent in the LCX lesion and a 2.5 * 24 mm Taxus™ stent in the 1st diagonal arterial lesion. After PCI, the patient became stable without chest pain and was discharged on the 10th hospital day. 2. Discussion To our knowledge, this is the first report of acute myocardial infarction ensued on scrub typhus. It had been known that the main pathologic findings in scrub typhus are systemic vasculitis and perivasculitis, which are caused by proliferation of O. tsutsugamushi in endothelial cells of microvascular system [1]. Liam and colleagues [2] reported the concept that acute infections are associated with a transient increase in the risk of vascular events. The mechanisms by which acute inflammation or infection affect the risk of vascular events is uncertain. There is the evidence that chronic inflammation
D.G. Kim et al. / International Journal of Cardiology 114 (2007) e18–e20
e19
Fig. 1. Electrocardiography showed ST elevation in V2, 3 with symmetric T inversion in V2-6 and I, aVL lead.
may promote atherosclerotic disease. Pro-inflammatory cytokines such as C-reactive protein are important mediators of immune response with respect to endothelial dysfunction in patients with coronary artery disease. Previous report demonstrated that systemic vasculitis in scrub typhus could induce the endothelial dysfunction [1]. Additionally, disseminated intravascular coagulation associated with endothelial
cellular injury caused by O. tsutsugamushi had been reported [1]. Therefore, the endothelial dysfunction caused by scrup typhus could be considered as the main mechanism. However, in the current case, the casual relation between scrub typhus infection and coronary event was not established. Considering the involvement of two vessels simultaneously, the scrup typhus may widely affect the plaque
Fig. 2. Coronary angiography showed a subtotal stenosis with TIMI 1–2 distal flow in the middle portion of left circumflex coronary artery (A) and a critical stenosis with TIMI 2–3 flow in the first diagonal branch (B).
e20
D.G. Kim et al. / International Journal of Cardiology 114 (2007) e18–e20
stability via endothelial dysfunction. In the future, further studies are warranted to clarify this issue in terms of epidemiological and pathological aspects. References [1] Levine HD. Pathologic study of 31 cases of scrub typhus fever with special reference to the cardiovascular system. Am Heart J 1964;31:481.
[2] Smeeth Liam, Thomas Sara L, Hall Andrew J, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611–8.
Letter to the Editor
Acute myocardial infarction following scrub typhus infection Dae Gyeun Kim a , Jin Won Kim b,⁎, Yoon Sun Choi a,⁎, Su Hyun Kim a , Seon Mee Kim a , Chang Gyu Park b , Hong Seog Seo b , Dong Joo Oh b a
Department of Family Medicine, Korea University Guro Hospital, 97 Guro-dong Gil, Guro-Gu, 152-703, South Korea b Cardiovascular Center, Korea University Guro Hospital, 97 Guro-dong Gil, Guro-gu, Seoul 152-703, South Korea Received 3 May 2006; accepted 22 July 2006 Available online 19 October 2006
Abstract Up to recently, a few cases of myocarditis in the cardiac manifestations of scrub typhus have been reported. However, acute myocardial infarction (AMI) associated with scrub typhus has not been previously reported. We presented a case of AMI ensued on scrub typhus, which were successfully treated by percutaneous coronary intervention (PCI). © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Scrup typhus; Acute myocardial infarction
1. Case A 58 year old man was admitted with febrile illness and generalized myalgia, which developed 7 days prior to admission. He was a 30 pack-year smoker without other risk factors and previous history of cardiovascular disease. On physical examination, a 13 * 11 mm-sized black-crusted shallow ulcer (eschar) was found on the medial aspect of right thigh. Laboratory data showed white blood cell count of 12,000/μL, total cholesterol 144 mg/dL and C-reactive protein 108.0 mg/dL. Serologic test for O. tsutsugamushi using indirect immunofluorescent assay antibody (IgM) was strong positive. Electrocardiography (ECG) showed normal sinus rhythm without any evidence of ischemic change. After 7 days oral doxycycline (200 mg per day) therapy, he was discharged free of previous symptoms. On 1 week after discharge, he was referred to our emergency room with squeezing chest pain lasting 3 h. On arrival, ECG showed ST elevation in V2, 3 with symmetric T ⁎ Corresponding authors. Kim is to be contacted at Tel.: +82 2 818 6851; fax: +82 2 818 6411. Choi, Tel.: +82 2 818 6886; fax: +82 2 837 3966. E-mail addresses: [email protected] (J.W. Kim), [email protected] (Y.S. Choi). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.07.131
inversion in V2-6 and I, aVL lead (Fig. 1). The levels of CKMB and troponin T were 24.7 and 0.117 ng/ml, respectively. Emergent coronary angiography showed a subtotal stenosis with TIMI 1–2 distal flow in the middle portion of left circumflex coronary artery (LCX) and a critical stenosis with TIMI 2–3 flow in the first diagonal branch (Fig. 2). We successfully performed stenting with a 2.75 * 23 mm Cypher™ stent in the LCX lesion and a 2.5 * 24 mm Taxus™ stent in the 1st diagonal arterial lesion. After PCI, the patient became stable without chest pain and was discharged on the 10th hospital day. 2. Discussion To our knowledge, this is the first report of acute myocardial infarction ensued on scrub typhus. It had been known that the main pathologic findings in scrub typhus are systemic vasculitis and perivasculitis, which are caused by proliferation of O. tsutsugamushi in endothelial cells of microvascular system [1]. Liam and colleagues [2] reported the concept that acute infections are associated with a transient increase in the risk of vascular events. The mechanisms by which acute inflammation or infection affect the risk of vascular events is uncertain. There is the evidence that chronic inflammation
D.G. Kim et al. / International Journal of Cardiology 114 (2007) e18–e20
e19
Fig. 1. Electrocardiography showed ST elevation in V2, 3 with symmetric T inversion in V2-6 and I, aVL lead.
may promote atherosclerotic disease. Pro-inflammatory cytokines such as C-reactive protein are important mediators of immune response with respect to endothelial dysfunction in patients with coronary artery disease. Previous report demonstrated that systemic vasculitis in scrub typhus could induce the endothelial dysfunction [1]. Additionally, disseminated intravascular coagulation associated with endothelial
cellular injury caused by O. tsutsugamushi had been reported [1]. Therefore, the endothelial dysfunction caused by scrup typhus could be considered as the main mechanism. However, in the current case, the casual relation between scrub typhus infection and coronary event was not established. Considering the involvement of two vessels simultaneously, the scrup typhus may widely affect the plaque
Fig. 2. Coronary angiography showed a subtotal stenosis with TIMI 1–2 distal flow in the middle portion of left circumflex coronary artery (A) and a critical stenosis with TIMI 2–3 flow in the first diagonal branch (B).
e20
D.G. Kim et al. / International Journal of Cardiology 114 (2007) e18–e20
stability via endothelial dysfunction. In the future, further studies are warranted to clarify this issue in terms of epidemiological and pathological aspects. References [1] Levine HD. Pathologic study of 31 cases of scrub typhus fever with special reference to the cardiovascular system. Am Heart J 1964;31:481.
[2] Smeeth Liam, Thomas Sara L, Hall Andrew J, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611–8.