CARDIAC TAMPONADE WITH HEMORRHAGIC PERICARDIAL EFFUSION AS A RESULT OF NOVEL SARS-COV-2 INFECTION

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac tamponade is a serious and life-threatening condition in which fluid accumulates in the pericardial space resulting in impaired ventricular filling and cardiac compression, leading to hemodynamic compromise and ultimately cardiac arrest. Cardiac tamponade, due to a hemorrhagic pericardial effusion, can be caused by various etiologies. Here, we present a rare case in which a hemorrhagic pericardial effusion with tamponade physiology is the initial presentation of the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, also known as COVID-19. CASE PRESENTATION: A previously healthy 32-year-old male presented to the emergency room with chief complaints of chest pain and increasing shortness of breath, over a one week duration. Testing revealed SARS-CoV-2 positivity by PCR. Evaluation included a computed tomography angiogram excluding pulmonary embolism but revealing a large pericardial effusion. Echocardiogram confirmed this finding and showed ventricular filling changes consistent with tamponade physiology. Shortly after, the patient began exhibiting signs of hemodynamic instability. Emergent pericardiocentesis ensued with placement of a pericardial drain. A pericardial window was performed the following day. Initial fluid analysis was consistent with an inflammatory process. Cytology was negative for malignancy. He was treated with colchicine, and gradually obtained resolution of all of his symptoms. He was discharged home in stable condition. DISCUSSION: With a volatile virus exhibiting versatile pathogenicity, it is of paramount importance to understand its mechanisms of action in order to both, better predict its role in the formation of a pericardial effusion and prevent the development of cardiac tamponade (2). As was seen with SARS-CoV back in 2002, the novel coronavirus also depends on its S protein, specifically the S1 subunit, to adhere to and enter the host cell via endocytic entry. The host cell receptor, angiotensin- converting enzyme 2 (ACE 2), is widely expressed throughout the body, with sites noted in arterial and venous endothelial cells, renal podocytes, alveolar epithelial cells, and cardiac myocytes. This, in addition to, the pro-inflammatory storm mediated by downregulation of ACE 2 and subsequent reduced levels of Ang 1-7 leads to increased levels of apoptosis and myocyte injury (3). High levels of inflammatory cells congregated at these sites can infiltrate the pericardium leading to pericarditis and resultant pericardial effusion. CONCLUSIONS: We report one of the first cases of a hemorrhagic pericardial effusion with cardiac tamponade physiology as the initial manifestation of a COVID-19 infection in an otherwise healthy, young male. This adds to the growing literature of extrapulmonary manifestations of a COVID-19 infection, as we continue to treat more afflicted patients in this constantly evolving pandemic of the 21st century (1). REFERENCE #1: Dabbagh, M. F., Aurora, L., D'Souza, P., Weinmann, A. J., Bhargava, P., & Basir, M. B. (2020). Cardiac Tamponade Secondary to COVID-19. JACC. Case reports, 10.1016/j.jaccas.2020.04.009. Advance online publication. https://doi.org/10.1016/j.jaccas.2020.04.009 REFERENCE #2: Farina, Andrea, et al. "SARS-CoV-2 Detection in the Pericardial Fluid of a Patient with Cardiac Tamponade." European Journal of Internal Medicine, vol. 76, 22 Apr. 2020, pp. 100–101., doi:10.1016/j.ejim.2020.04.045. REFERENCE #3: Wang, Dawei, et al. "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China." Jama, vol. 323, no. 11, 2020, p. 1061., doi:10.1001/jama.2020.1585. DISCLOSURES: No relevant relationships by Sabaa Ahmed, source=Web Response No relevant relationships by Nancy Guirguis, source=Web Response