Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

Abstract

Importance: Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objective: To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms.

Design, setting, and participant: This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course.

Exposure: Cardiac involvement with COVID-19.

Main outcomes and measures: Detection of cardiac involvement with an increase in levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging.

Results: An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization.

Conclusions and relevance: This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Farina has received personal fees from Bayer and Bracco Group. Dr Metra has received personal fees from Abbott Vascular, Amgen, Bayer, Edwards Therapeutics, and Vifor Pharma. No other disclosures were reported.

Figures

Figure 1.. Electrocardiographic and Chest Radiographic Findings

A, Electrocardiography showing sinus rhythm with low voltage in the limb leads, diffuse ST-segment elevation (especially in the inferior and lateral leads), and ST-segment depression with T-wave inversion in leads V1 and aVR. B, Posteroanterior chest radiography at presentation. No thoracic abnormalities were noted.

Figure 2.. 1.5-T Cardiac Magnetic Resonance Imaging

Short tau inversion recovery (STIR) sequences in short-axis view (A) and 4-chamber view (B) showed diffuse myocardial signal hyperintensity of the biventricular wall, suggesting interstitial edema. Results were confirmed on the T2-mapping sequences in short-axis view (C) and 4-chamber view (D). Phase-sensitive inversion recovery (PSIR) sequences in short-axis view (E) and 4-chamber view (F) showed diffuse biventricular late gadolinium enhancement. All images demonstrated a circumferential pericardial effusion, especially around the right ventricle.