TAKOTSUBO CARDIOMYOPATHY TRIGGERED BY CORONAVIRUS NL63 IN A COVID-19 PANDEMIC

Abstract

TOPIC: Critical Care TYPE: Global Case Reports INTRODUCTION: Stress-induced cardiomyopathy cases have increased with COVID-19 pandemic, whether as a direct cardiac cause of SARS CoV2 infection or as a consequence of prolonged social isolation and multiple factors disrupting mental health. Among the different types of Coronaviruses, NL63 usually tends to present with mild respiratory and systemic symptoms. This case uniquely demonstrates how other members of the Coronavirus family may also afflict patients with Takotsubo cardiomyopathy. CASE PRESENTATION: 61-year-old male with history significant for multiple respiratory and urinary infections, CHF, CAD, CABG and recent hospitalization for bacterial pneumonia. Chest CT showed ground glass opacities on that admission though improved from 2 months prior. PCR was positive for HCoV-NL63 and was negative for SARS CoV2. He was admitted to the hospital with a fever, productive cough, shortness of breath and 10 lbs weight loss for two weeks. WBC 5,400 with subtle lymphocytopenia, Hgb 15.3 g/dL, platelets 218,000, normal renal function, PCT normal, Hgb A1C 6.0, and CXR negative for acute lung disease. Due to respiratory symptoms and the ongoing pandemic, he was retested for SARS CoV2, which was negative. EKG was negative for ischemia. CRP was elevated at 2.28 that trended down on Meropenem as prior sputum cultures grew Pseudomonas, Serratia and E. Coli. He had a normal initial Troponin that peaked to 2.94, Echocardiogram showed an EF of 20%, with apical ballooning consistent with Takotsubo cardiomyopathy as well as a mobile hyperechoic right atrial structure felt to be a thrombus extending from the SVC and no evidence of endocarditis. An echocardiogram 10 days prior showed an EF of 50-55% with mild diastolic dysfunction without any hyperechoic lesions or valvular abnormalities. On Day 4 he required pressor support while cultures grew fungi for which he was started on fluconazole. Subsequently, Cryptococcus Neoformans was isolated in the CSF and Amphotericin B was added to an increased dose of fluconazole.As he showed signs of volume overload and increased oxygen demands he was treated with loop diuretics, ACE inhibitors, and beta blockers.He was transferred for a TEE to a tertiary care facility and was treated for 42 days with Amphotericin B, Diflucan and Lactulose for hyperammonemia. He completed 6 month therapy with fluconazole.On return to his PCP he was mentating appropriately, is walker dependent and is undergoing B Cell Phenotype testing given his immunocompromised state and recurrent infections. DISCUSSION: This complicated case higlights the possibility of a Takotsubo due to Coronavirus NL63 in a immunosuppressive state. CONCLUSIONS: The presence of a viral respiratory infection due to Coronavirus NL63 presumptively triggered stress induced cardiomyopathy which responded with supportive care during a Covid-19 pandemic in a immunosuppressed patient without evidence of SARS CoV2. REFERENCE #1: Corman VM, Lienau J, Witzenrath M. Coronaviren als Ursache respiratorischer Infektionen [Coronaviruses as the cause of respiratory infections]. Internist (Berl). 2019;60(11):1136-1145. doi:10.1007/s00108-019-00671-5 REFERENCE #2: Jabri A, Kalra A, Kumar A, et al. Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020;3(7):e2014780. Published 2020 Jul 1. doi:10.1001/jamanetworkopen.2020.14780 DISCLOSURES: No relevant relationships by Pablo Echeverria, source=Web Response No relevant relationships by Andrew Mahtani, source=Web Response No relevant relationships by Anum Niazi, source=Web Response No relevant relationships by Luis Paz y Mino, source=Web Response No relevant relationships by Julia Saa, source=Web Response