SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: The prevalence of myocarditis in COVID-19 remains unknown as diagnosing myocarditis can be challenging. As per an estimate, up to 7% of death in Covid-19 might be related to myocarditis (1).
CASE PRESENTATION: A 60-year-old male with a medical history of hypertension, type II diabetes presented with cough and worsening dyspnea for 8 days. In ER, he was hypoxic (SpO2 75% on room air) requiring intubation for respiratory failure. Chest Xray showed bilateral diffuse opacities (Fig 1). SARS-Cov2 Rt-PCR was positive. Labs were significant for leukocytosis, elevated troponin, inflammatory markers, and abnormal liver, renal function tests (Tab 1). EKG (Fig 2) showed age indeterminate inferior infarct versus left anterior fascicular block. In the ICU, the patient was in shock with multi-organ failure requiring 4 vasoactive drugs. 2D ECHO showed EF <30% along with akinesis of the mid to apical myocardial segments (Fig 3). The shock was believed to be cardiogenic and distributive (PaSat 95%). Vancomycin and Cefepime were administered. He received Immunoglobulins (IVIG) for suspicion for viral myocarditis and pulse dose steroids for the cytokine storm. Renal replacement therapy was initiated for acute kidney injury and N acetylcysteine for acute liver injury. The patient had uncontrolled hyperglycemia requiring insulin drip. After 3 days of intensive therapy, the vasoactive agents were weaned off as the patient showed significant clinical improvement. The cultures showed no growth. EKG (Fig 4) showed nonspecific T wave changes however, myocardial infarction findings were no longer present. A repeat 2D ECHO on day 10 showed normalization of ventricular function. Despite antibiotics, he continued to be febrile with persistent leukocytosis. On day 13, Voriconazole was started for aspergillus fumigatus in respiratory culture and elevated fungitell level. By day 20, he was successfully liberated off the ventilator with minimal oxygen supplementation. He was discharged to acute rehabilitation on day 46 with outpatient hemodialysis.
DISCUSSION: The pathophysiology of COVID-19-related myocarditis is thought to be a combination of direct viral injury and cardiac damage due to the host’s immune response (2). The hypothesis behind the use of intravenous immunoglobulin (IVIG) is that it may replace antibodies, augment viral clearance, and enhance clearance of inflammatory cytokines that contribute to myocyte destruction. IVIG therapy has been linked with the superior recovery of left ventricular function and lower mortality in patients with acute myocarditis (3). However, the use of Immunoglobulins in myocarditis remains controversial.
CONCLUSIONS: In our case, early aggressive treatment of suspected myocarditis with IVIG therapy likely contributed to our patient’s rapid recovery. A large randomized controlled trial is required to determine the efficacy of immunoglobulins in Covid-19 related myocarditis.
Reference #1: Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. J Am Coll Cardiol. 2020;75(18):2352-2371. doi:10.1016/j.jacc.2020.03.031
Reference #2: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: the possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020;S1547-5271(20)30422-7. doi:10.1016/j.hrthm.2020.05.001
Reference #3: Huang X, Sun Y, Su G, Li Y, Shuai X. Intravenous Immunoglobulin Therapy for Acute Myocarditis in Children and Adults. Int Heart J. 2019;60(2):359-365. doi:10.1536/ihj.18-299
DISCLOSURES: No relevant relationships by NEHA DEVAL, source=Web Response
No relevant relationships by Anant Jain, source=Web Response
No relevant relationships by Lisa Paul, source=Web Response