COVID-19 INDUCED MYOPERICARDITIS AND CARDIAC TAMPONADE: A DIAGNOSTIC DILEMMA

Background:

According to the WHO, there have been more that 230 million confirmed cases of SARS-CoV-2 as of October 2021. The disease process is largely characterized by an acute severe respiratory illness. Hence, cardiac disease may initially be overlooked. However, as cases continue to rise, cardiac manifestations have become more prevalent. Fulminant myopericarditis is a rare manifestation of coronavirus disease that may result in rapid clinical deterioration and death.

Case:

54-year-old female with asthma presented with constitutional symptoms, exertional dyspnea, vomiting, diarrhea and a positive COVID test. She denied any anginal symptoms. On presentation her vital signs included a blood pressure of 83/50, temperature of 38 °C, and pulse oximetry of 98%. Initial work-up showed elevated troponin, and proBNP. EKG showed sinus tachycardia with diffuse low voltage QRS, and POCUS revealed EF 25%, IVC plethora, and a small pericardial effusion.

Decision-making:

At this point the differential remained broad including septic shock, COVID pneumonia, NSTEMI, acute systolic CHF, and stress cardiomyopathy. The patient suddenly decompensated with a blood pressure of 64/52 requiring increased pressor support. Repeat ECHO showed worsening ejection fraction (EF) 7% and global hypokinesis and features suspicious of myopericarditis. PA catheterization revealed equalization of pressure now raising concerns of superadded cardiac tamponade. The patient required immediate pericardiocentesis and insertion of Impella device to maintain cardiac output. After 2 weeks on ventricular support, she had improved cardiac function with EF 60% and normal wall motion.

Conclusion:

This case raises two valuable points. Firstly, it is important to consider cardiac pathology in all patients presenting with COVID related disease, especially when faced with sudden clinical deterioration. Early echocardiography and invasive cardiac monitoring may be valuable in identifying these individuals. This is especially true in cases of hemodynamic instability where further imaging such as cardiac MRI are not feasible. Secondly, early implementation of ventricular support devices can be a life saving strategy.