Fulminant myocarditis in a COVID-19 positive patient treated with mechanical circulatory support – a case report

Abstract

Background Coronavirus disease 2019 (COVID-19) spreading from Wuhan, Hubei province in China, is an expanding global pandemic with significant morbidity and mortality. Even though respiratory failure is the cardinal form of severe COVID-19, concomitant cardiac involvement is common. Myocarditis is a challenging diagnosis due to heterogeneity of clinical presentation, ranging from mild symptoms to fatal arrhythmia and cardiogenic shock (CS). The aetiology is often viral and endomyocardial biopsy (EMB) is the gold standard for definite myocarditis. However, the diagnosis is often made on medical history, clinical presentation, magnetic resonance imaging, and blood tests. Case summary We present a 43-year-old man with mixed connective tissue disease treated with hydroxychloroquine who rapidly developed CS 4 days from symptom onset with fever and cough, showing positive polymerase chain reaction nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. While computed tomography of the thorax was normal, high-sensitivity troponin T was elevated and electrocardiogram showed diffuse ST elevation and low voltage as signs of myocardial oedema. Echocardiography showed severe depression of left ventricular function. The myocardium recovered completely after a week with mechanical circulatory support (MCS). EMB was performed but could neither identify the virus in the cardiomyocytes, nor signs of inflammation. Still the most probable aetiology of CS in this case is myocarditis as a sole symptom of COVID-19. Discussion COVID-19 patients in need of hospitalization present commonly with respiratory manifestations. We present the first case of fulminant myocarditis rapidly progressing to CS in a COVID-19 patient without respiratory failure, successfully treated with inotropes and MCS.

The Pathogenesis and Long-Term Consequences of COVID-19 Cardiac Injury

“… 49 , 50 , 51 , 52 , 53 Although most of these patients are young and recovered fully after pharmacologic management, some patients progressed to require durable mechanical circulatory support in response to persistent severe ventricular dysfunction. 54 Because of the nonspecificity of COVID-19-related myocarditis reported to date, other diagnoses should also be considered and a clear diagnostic algorithm used. 22 The clinical characteristics of reported cases of COVID-19-related myocarditis (as of September 2021) are summarized in Supplemental Table 1 .…”

Coronavirus Disease-2019 and Heart Failure: A Scientific Statement From the Heart Failure Society of America

“…Data regarding the use of temporary MCS for patients with COVID-19 and cardiogenic shock are primarily limited to case reports and small case series. 69 , 70 , 71 Cardiogenic shock in patients with COVID-19 should thus be managed similarly to those without COVID-19, with appropriate pharmacological therapies selected based on clinical presentation. If MCS is indicated, veno-arterial extracorporeal membrane oxygenation (VA ECMO) is often preferred for hemodynamic support as well as oxygenation, as most patients have significant coexisting pneumonia.…”

Multisystem inflammatory syndrome in adults (MIS-A) following COVID-19 requiring venoarterial extracorporeal membrane oxygenation

“…To date, only a few cases of VA-ECMO use in patients with MIS-A from COVID-19 infection have been reported. [7][8][9] Our study reports one of the oldest patients with MIS-A treated with both Impella and VA-ECMO and indicates that even on the severe spectrum of the disease, prognosis can be good.…”