FULMINANT MYOCARDITIS IN A PATIENT WITH SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV2) has lead to unprecedented morbidity and mortality seen in modern times. In addition to acute respiratory distress syndrome (ARDS), there is a range of multi-organ dysfunction complications including fulminant myocarditis. CASE PRESENTATION: A 61 year old male presented with 6 days of fever, malaise, dyspnea, and cough. He was previously seen with similar symptoms and discharged on azithromycin with instructions to self-isolate. Medical history includes hypertension and hypothyroidism. On exam he was in respiratory distress with severe hypoxia on non-re-breather mask requiring emergent intubation and bilateral crepitations. EKG showed sinus tachycardia with diffuse ST depressions. Labs revealed leukocytosis 12K/uL, lactic acidosis 7.8mmol/L, procalcitonin 17.8ng/mL, troponin peaked at 17.7ng/mL, thyroid function was normal, and d-dimer was >20ug/mL. Chest x-ray showed diffuse bilateral interstitial opacities and small left pleural effusion. Echocardiogram revealed global hypokinesis with left ventricular ejection fraction 30% and small pericardial effusion with visceral thickening. SARS-COV2 PCR testing was positive. Testing for influenza, S. pneumonia, and legionella were negative. He developed shock and was placed on norepinephrine, furosemide, cefepime, doxycycline, hydroxychloroquine, therapeutic dose enoxaparin, and high dose methylprednisone. His ventilator settings were placed with high positive end-expiratory pressures and low tidal volumes. He was deemed too unstable to prone; extracorporeal membrane oxygenation (ECMO), as well as, intravenous immunoglobulin treatment were being considered. Unfortunately, he had cardiac arrest and died despite resuscitation efforts. DISCUSSION: Viral myocarditis is a recognized cause of heart failure and cardiogenic shock. Ideally, ischemic cardiomyopathy should be excluded via coronary angiogram but non-invasive methods such as echo or cardiac MRI may be suggestive (acute global hypokinesis or regional wall motion abnormalities that do not match coronary vessel anatomy).1 The proposed mechanisms of myocyte damage include: active replication of live virus within the myocardium, cytokine release due to innate immune response, viral proteins that cause direct myocardial injury, lymphocyte-mediated myocardial injury, inhibition of heme metabolism, and hypercoagulable state leading to microthrombi in small coronary vessel thrombosis as well as pulmonary emboli.2 Current treatment options involve anti-platelets/anticoagulation, antivirals and anti-malarials, high dose steroids, immunoglobulin, ECMO, and plasma exchange.3 CONCLUSIONS: The management of critically ill patients with SARS-COV2 is challenging and multifaceted. The course may be complicated by fulminant myocarditis with cardiogenic shock for which the prognosis can be grave despite the current treatment methods. Reference #1: Michael Jeserich, Stavros Konstantinides, Gabor Pavlik, Christoph Bode, and Annette Geibel. Non-invasive imaging in the diagnosis of acute viral myocarditis. Clin Res Cardiol. 2009 Dec; 98(12): 753–763. Published online 2009 Sep 11. doi: 10.1007/s00392-009-0069-2 Reference #2: Toshitaka Yajima and Kirk U. Knowlton. Viral Myocarditis. Circulation. 2009;119:2615–2624 https://doi.org/10.1161/CIRCULATIONAHA.108.766022 Reference #3: Riccardo M. Inciardi, MD; Laura Lupi, MD; Gregorio Zaccone, MD; et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. Published online March 27, 2020. doi:10.1001/jamacardio.2020.1096 DISCLOSURES: No relevant relationships by Lakshmi Ayyagari, source=Web Response No relevant relationships by Jason Lofters, source=Web Response No relevant relationships by John Lui, source=Web Response No relevant relationships by Gene Otuonye, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response