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Fulminant myocarditis in a COVID-19 positive patient treated with mechanical circulatory support - a case report
Joanna-Maria Papageorgiou1, Henrik Almroth1, Mattias Törnudd2
1Department of Cardiology, Linköping University Hospital, SE-58185 Linköping, Sweden.
Insights
This case study highlights a patient with COVID-19 who developed fulminant myocarditis and cardiogenic shock without respiratory failure. Prompt treatment with mechanical circulatory support led to complete myocardial recovery, demonstrating a rare presentation of coronavirus disease 2019.
Area of Science:
- Cardiology
- Infectious Diseases
- Critical Care Medicine
Background:
- Coronavirus disease 2019 (COVID-19) is a global pandemic with significant mortality, often presenting with respiratory failure but also cardiac involvement.
- Myocarditis, inflammation of the heart muscle, can range from mild to fatal, with cardiogenic shock (CS) being a severe complication.
- Diagnosis of myocarditis is challenging, relying on clinical presentation, imaging, and blood tests, as endomyocardial biopsy (EMB) is not always definitive.
Purpose of the Study:
- To report the first case of fulminant myocarditis leading to cardiogenic shock as the sole manifestation of COVID-19 in a patient without respiratory failure.
- To illustrate the successful management of severe COVID-19-associated myocarditis with mechanical circulatory support (MCS).
Main Methods:
- A 43-year-old male with mixed connective tissue disease presented with COVID-19 symptoms and rapidly developed cardiogenic shock.
- Diagnostic workup included polymerase chain reaction (PCR) for SARS-CoV-2, electrocardiogram (ECG), echocardiography, and endomyocardial biopsy (EMB).
- Treatment involved mechanical circulatory support (MCS) and inotropic agents.
Main Results:
- The patient tested positive for SARS-CoV-2 RNA and showed ECG and echocardiographic signs of myocardial edema and severe left ventricular dysfunction.
- Despite negative findings on EMB for viral or inflammatory markers, myocarditis was the presumed cause of CS.
- Complete myocardial recovery was achieved within a week with MCS.
Conclusions:
- Fulminant myocarditis can be the primary presentation of COVID-19, even in the absence of respiratory failure.
- Mechanical circulatory support is a viable and effective treatment for COVID-19-induced cardiogenic shock due to myocarditis.
- This case underscores the importance of considering cardiac complications in COVID-19 patients, regardless of respiratory symptoms.
Background:
Coronavirus disease 2019 (COVID-19) spreading from Wuhan, Hubei province in China, is an expanding global pandemic with significant morbidity and mortality. Even though respiratory failure is the cardinal form of severe COVID-19, concomitant cardiac involvement is common. Myocarditis is a challenging diagnosis due to heterogeneity of clinical presentation, ranging from mild symptoms to fatal arrhythmia and cardiogenic shock (CS). The aetiology is often viral and endomyocardial biopsy (EMB) is the gold standard for definite myocarditis. However, the diagnosis is often made on medical history, clinical presentation, magnetic resonance imaging, and blood tests.
Case Summary:
We present a 43-year-old man with mixed connective tissue disease treated with hydroxychloroquine who rapidly developed CS 4 days from symptom onset with fever and cough, showing positive polymerase chain reaction nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. While computed tomography of the thorax was normal, high-sensitivity troponin T was elevated and electrocardiogram showed diffuse ST elevation and low voltage as signs of myocardial oedema. Echocardiography showed severe depression of left ventricular function. The myocardium recovered completely after a week with mechanical circulatory support (MCS). EMB was performed but could neither identify the virus in the cardiomyocytes, nor signs of inflammation. Still the most probable aetiology of CS in this case is myocarditis as a sole symptom of COVID-19.
Discussion:
COVID-19 patients in need of hospitalization present commonly with respiratory manifestations. We present the first case of fulminant myocarditis rapidly progressing to CS in a COVID-19 patient without respiratory failure, successfully treated with inotropes and MCS.
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