COVID-19 induced myocarditis with heart failure and severe pneumonia
This article describes the case of a 38-year-old woman who presented to the hospital with a history of 15 days of fever and 3 days of dyspnea. The patient had tested positive for the PCR SAR-CoV-2 test. In addition, the patient was also at a high probability of having myocarditis based on the Lake Louise criteria. Although it is not known how common myocarditis is in COVID-19 patients, it has been identified as a cause of death in COVID-19 patients. Moreover, early detection and timely treatment are critical for successful treatment outcomes. Currently, an MRI of the cardiovascular system is the most important investigation for the diagnosis of myocarditis. In this case, the patient developed acute myocarditis after COVID-19.
Case study
The 38-year-old patient presented to the hospital with no cardiac abnormalities and dyspnoea with a 15-day history of fever. She further had a 5-day history of dry cough and tested positive for COVID-19. 3 days before she was admitted she had paroxysmal nocturnal dyspnoea and breathing problems while walking. The patient was admitted to a nearby hospital where doctors treated her with vasopressor medications for hypotension and severe dyspnea.
On admission, doctors referred the patient for an ECG which showed a sinus rhythm of 158 beats per minute, in addition to ST elevation, and QS waves in the inferior V1 and V2 leads. The ECG further showed an ejection fraction of 40% and septal wall hypokinesis. The patient was further referred for a CT scan of the chest which showed ground-glass opacification lesions in both lungs. However, there were no signs of pulmonary embolism. The patient had a negative fast COVID-19 test. Doctors started treatment with 15 L/min oxygen supplement, noradrenaline and dobutamine. Based on the ST elevation, the patient was diagnosed with myocardial infarction. She was then transferred to University Medical Hospital Medical Centre Ho Chi Minh City for primary PCI (percutaneous coronary intervention).
COVID-19 associated myocarditis which aggravated severe acute heart failure
The patient was conscious at the emergency department. Examination showed cold extremities with a weak pulse of 130 bpm, blood pressure 110/60 mmHg and oxygen saturation of 96% oxygen with a 15/ L/m mask. In addition, there were signs of moist coarse rales on both lungs. Doctors advised a routine chest radiograph which showed evidence of peri-bronchial cuffing and an elevated cardiothoracic ratio. ECG showed a 120-bpm sinus rhythm. The laboratory tests also showed an elevated hs-troponin T at 1716 ng/L, D-dimer was 10880 ng/mL, LDH was 782.80 U/L, ferritin was 7861 ng/mL, and IL-6 was 66.71 pg/mL. At this point her PCR SARS-Cov-2 result was positive. She was kept on a 15 L/m oxygen mask, intravenous furosemide, dobutamine and noradrenaline. She was then referred to the Intravenous Cardiology Department where doctors diagnosed her with COVID-19 induced cardiac failure and severe pneumonia.
Treatment and prognosis
For the next 72 hours, the patient remained conscious and her blood pressure ranged from 85/50 and 120/70 mmHg. She was continued on nasal oxygen supplementation with 5 L/m flow. In addition, a new chest X-ray was advised which showed a significant improvement in the chest congestion. She was kept on dobutamine a few days after, also. The patient was kept on dobutamine for a few days after with intravenous furosemide and spironolactone and concomitant oral digoxin. Doctors further advised a cardiac MRI which showed a severely reduced ejection fraction in the left ventricle, a mildly dilated left ventricle and hypokinesis in the septal region and left free ventricular wall. In addition, there was myocardial hyperintensity in the left ventricular wall and late gadolinium enhancement (LGE) of cardiac muscles with a non-ischemic pattern.
Doctors advised an angiography of the coronary arteries which showed no signs of major stenosis in the main arteries. Doctors eventually diagnosed the patient with COVID-19 associated myocarditis which aggravated severe acute heart failure. The case study further states that the patient was started on 100 mg sacubitril/valsartan and 2.5 mg bisoprolol daily. There were no signs of fever or dyspnoea and she had a normal appetite. Other test results were also within the normal range. The patient was referred for another echocardiogram after the termination of the dobutamine. The results were consistent with no dilated chambers, dyskinesia and a 57% left ventricular ejection fraction. In addition, there were no other significant abnormalities. She had a satisfactory rehabilitation period. She was called back for a follow up 2 weeks after which showed no irregularities.
Source: American Journal of Case Reports
