COVID-19 INFECTION IN A PATIENT WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: As we navigate through the Covid pandemic, there is emerging evidence of cardiac injury related to Covid-19 infection such as myocardial ischemia, arrhythmia and pericardial effusion. Studies have associated Covid-19 related cardiac injury with a 5-fold increase in the risk of mechanical ventilation and 14 times higher mortality rate(1). In the presence of cardiac co-morbidities, Covid-19 related all-cause mortality rate increases. We present a case of Covid-19 infection in a patient with Hypertrophic Obstructive Cardiomyopathy (HCM) intending to discuss its sequelae. CASE PRESENTATION: A 72-year old male presented to ER with 2 days history of non-productive cough and dyspnea. Six months ago, he was hospitalized for 8 days with respiratory failure secondary to Covid-19 pneumonia. He was treated with remdesivir, ceftriaxone, azithromycin and dexamethasone. His past history was significant for HCM status post AICD placement, chronic diastolic heart failure with ejection fraction of 55% and hypertension.On presentation, he was hypotensive at 83/50, with a heart rate of 58 and saturation of 94% on room air. His WBC count was elevated at 12.2. Chest x-ray revealed right basal infiltrate with bilateral small pleural effusions. His presentation ECG revealed new onset atrial fibrillation (AF). Covid PCR test was negative. He was admitted to intensive care unit for vasopressor support for management of septic shock secondary to pneumonia.Therapeutic dose of enoxaparin was initiated in view of AF with CHA2DS2VASC score of 3. Echocardiogram showed mild concentric left ventricular hypertrophy with ejection fraction of 55-60%. Significant left ventricular outflow tract gradient consistent with HCM was noted. Due to worsening of bilateral pleural effusions, bilateral thoracocentesis was performed separately draining 650ml of hemorrhagic fluid on the left and 800ml of hemorrhagic fluid on the right. Pleural fluid (PF) analysis was exudative and cytology was negative. Re-accumulation of PF warranted bilateral chest drain placement. PF culture remained negative. Unfortunately, patient had recurrent hypovolemic shock and he opted for comfort care measures. DISCUSSION: ACE2 receptor in the respiratory epithelium serves as the entry portal for the SARS-CoV-2 virus. In patients with HCM, there is up-regulation of ACE2 expression causing a 5-fold increase in ACE2 protein in sarcomeres, thereby increasing susceptibility to cardiac complications (2). Our patient in discussion had new onset AF, on the background of HCM. CONCLUSIONS: Reports indicate an increased incidence of cardiac complications in HCM patients with Covid-19 infection such as arrhythmia, as in our patient. AF in the setting of underlying HCM, can be explained by ACE2 protein up-regulation. Physicians managing HCM patients should well be aware of increased risk of such complications. REFERENCE #1: Toloui A, Moshrefiaraghi D, Madani Neishaboori A, Yousefifard M, Haji Aghajani M. Cardiac Complications and Pertaining Mortality Rate in COVID-19 Patients;a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2021 Feb 13;9(1):e18. doi: 10.22037/aaem.v9i1.1071. PMID: 33870205;PMCID: PMC8035700. REFERENCE #2: Bos JM, Hebl VB, Oberg AL, Sun Z, Herman DS, Teekakirikul P, Seidman JG, Seidman CE, Dos Remedios CG, Maleszewski JJ, Schaff HV, Dearani JA, Noseworthy PA, Friedman PA, Ommen SR, Brozovich FV, Ackerman MJ. Marked Up-Regulation of ACE2 in Hearts of Patients With Obstructive Hypertrophic Cardiomyopathy: Implications for SARS-CoV-2-Mediated COVID-19. Mayo Clin Proc. 2020 Jul;95(7):1354-1368. doi: 10.1016/j.mayocp.2020.04.028. Epub 2020 Apr 28. PMID: 32448590;PMCID: PMC7186205. DISCLOSURES: No relevant relationships by Khushdeep Chahal, source=Web Response No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Kavitha Juvvala, source=Web Response No relevant relationships by Eileen Montalvan, source=Web Response No relevant relationships by Utibe Ndebbio, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response