First case of COVID-19 complicated with fulminant myocarditis: a case report and insights

Abstract

Background Coronavirus disease 2019 has been demonstrated to be the cause of pneumonia. Nevertheless, it has not been reported as the cause of acute myocarditis or fulminant myocarditis. Case presentation A 63-year-old male was admitted with pneumonia and cardiac symptoms. He was genetically confirmed as having COVID-19 according to sputum testing on the day of admission. He also had elevated troponin I (Trop I) level (up to 11.37 g/L) and diffuse myocardial dyskinesia along with a decreased left ventricular ejection fraction (LVEF) on echocardiography. The highest level of interleukin-6 was 272.40 pg/ml. Bedside chest radiographs showed typical groundglass changes indicative of viral pneumonia. Laboratory test results for viruses that cause myocarditis were all negative. The patient conformed to the diagnostic criteria of the Chinese expert consensus statement for fulminant myocarditis. After receiving antiviral therapy and mechanical life support, Trop I was reduced to 0.10 g/L, and interleukin-6 was reduced to 7.63 pg/mL. Moreover, the LVEF of the patient gradually recovered to 68%. The patient died of aggravation of secondary infection on the 33rd day of hospitalization. Conclusion COVID-19 patients may develop severe cardiac complications such as myocarditis and heart failure. This is the first report of COVID-19 complicated with fulminant myocarditis. The mechanism of cardiac pathology caused by COVID-19 needs further study.

Prevalence and Impact of Myocardial Injury in Patients Hospitalized with COVID-19 Infection

“…Despite several reports of COVID-19 associated myocarditis, to date, one case (14) demonstrated detection of SARS-CoV-2 viral particles in cardiac tissue but no case has demonstrated COVID-19 genome in cardiac tissue on biopsy or autopsy accompanied by troponin elevation consistent with criteria used to diagnose myocarditis (3,4,(15)(16)(17). Other postulated mechanisms by which COVID-19 leads to cardiovascular morbidity include direct myocardial injury as a result of the inflammatory cascade or cytokine release, microvascular damage due to disseminated intravascular coagulation and thrombosis, direct entry of SARS-CoV-2 into myocardial cells by binding to ACE2 receptors, hypoxemia combined with increased metabolic demands of acute illness leading to myocardial injury akin to Type 2 Myocardial Infarction, and finally acute coronary syndrome from acute inflammation-triggered destabilization of atheromas (18)(19)(20).…”

“…The mode of infection of COVID-19 is thought to be direct entry of the SARS-CoV-2 virus into cells via the human angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed predominantly in the lungs but also throughout the cardiovascular system (1). Thus, while the most virulent manifestation of COVID-19 is acute respiratory distress syndrome (ARDS), select reports from Europe and China have also demonstrated cardiac injury reflected through elevated troponin concentrations among infected patients (2)(3)(4)(5). In these limited case series, troponin elevation was more common in patients with preexisting cardiovascular disease and, when present, was associated with higher rates of adverse outcomes in patients hospitalized with COVID-19 (6).…”

Human iPSC-Derived Cardiomyocytes are Susceptible to SARS-CoV-2 Infection

“…Alternatively, cardiac tissue expresses the ACE2 receptor, further suggesting feasibility of direct viral internalization in cardiomyocytes (Chen et al, 2020). Indeed, case studies have raised suspicion for cardiac injury mediated by direct myocardial viral infection and resulting fulminant myocarditis (Hu et al, 2020;Tavazzi et al, 2020;Zeng et al, 2020). In order to gain further insights into the cardiac pathophysiology of COVID-19, it will be critical to determine whether SARS-CoV-2 can directly infect isolated human cardiomyocytes in vitro.…”

COVID-19: Therapeutics and Their Toxicities

“…Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes coronavirus disease 2019 (COVID- 19), an infection characterized by flu-like symptoms, progressing in some cases to acute respiratory distress syndrome (ARDS) [1,2] or myocarditis [3][4][5][6]. COVID-19 was classified as a pandemic by the World Health Organization (WHO) on March 11, 2020.…”