COVID-19 related myopericarditis and cardiac tamponade: a diagnostic conundrum

We report the case of a 45-year-old man presenting with worsening shortness of breath and chest tightness on a background of type 2 diabetes mellitus, hypertension and stable angina. He felt generally unwell and had a productive cough two weeks prior to presentation. Initial examination found quiet heart sounds and reduced air entry bi-basally on auscultation. Electrocardiography (ECG) demonstrating lateral T-wave flattening and ongoing chest tightness directed management towards an acute coronary syndrome (ACS). However, negative troponin I and positive D-dimer prompted investigation with computed tomography pulmonary angiogram (CTPA) identifying a 3.5 cm thickness pericardial effusion and no pulmonary embolism. Initial COVID-19 nasopharyngeal swabs were negative for SARS-CoV-2. Echocardiography identified features consistent with cardiac tamponade prompting pericardiocentesis. Over 1,000 ml of straw-coloured aspirate was drained with significant clinical improvement, and the patient was discharged with plans for urgent outpatient cardiac magnetic resonance imaging (MRI). Interestingly, despite multiple negative nasopharyngeal swabs for COVID-19, serum antibodies to SARS-CoV-2 were detected.