Parvovirus infection causing prolonged QT intervals and cardiac arrest

ABSTRACT

AimsTo review an unusual case of an infant presenting with parvovirus infection causing prolonged QT intervals and cardiac arrest.MethodsWe reviewed the case history of the patient to discuss the presentation, management and progress since admission.ResultsA 14-month-old boy presented with cough and increased work of breathing for 1 day at district general hospital. He had suspected Parvovirus infection (causing slapped cheeks) 10 days ago. Due to worsening respiratory distress he was tried with various non invasive respiratory support. As he was not responding, he was intubated and ventilated. He was covered with ceftriaxone and acyclovir. During intubation he developed cardiac arrest requiring chest compressions,1 dose of adrenaline and a normal saline bolus. Return of spontaneous circulation happened after 2 minutes. He was transferred to tertiary unit for continuation of care. 2D ECHO showed normal cardiac structure with normal coronary arteries, but markedly dilated left ventricle, left atrium with left ventricular ejection fraction 30%. His was supported with milrinone and adrenaline as inotropes. He was transferred to quaternary centre in view of ECG changes of prolonged QT interval (600msec) global T wave inversion, broad based T wave, poor R wave progression across precordial leads. He was admitted there for 3 weeks before getting discharged to DGH. He received aspirin, bisoprolol, captopril, magnesium strycophosphate, furosemide, spironolactone, lactulose, melatonin, nystatin. After discharge at 1month follow up LVEF was 35%. His NT proBNP peaked to 35000pg/ml during intensive care admission which subsequently normalised to 3000. At discharge QT interval normalised to 480 msec with normal T wave morphology. 24-hour Holter showed sinus rhythm and inverted T waves. Blood cultures showed staphylococcus aureus for which he received 14 days of IV flucloxacillin. His respiratory secretions showed enterovirus, adenovirus and coronavirus 63. His acute kidney injury also resolved. He had normal EEG. His genetic tests for mitochondrial DNA WLS panel and family (parents’ and sibling) genetic tests for prolonged QT were normal. He was seen at cardiac function clinic and inherited arrythmia clinic and diuretics and beta blockers were stopped. Follow up plan about phenotypic exercise testing at later age and avoiding medications causing prolonged QT interval was agreed.ConclusionParvovirus infection can cause transient prolongation of QT interval which can precipitate cardia arrest. In these rare events supporting the child through the acute phase of illness ensures gradual recovery and improvement of the QT prolongation. Currently its not understood as to why this happens but could be postulated to an underlying myocarditis or inflammatory event causing changes in the conducting systems.