Suspected COVID-19 Induced Acute Viral Myocarditis

Abstract

Introduction: COVID-19 virus has been known to be a major cause of mortality secondary to cytokine storm and respiratory failure. Other manifestations include GI symptoms, loss of taste and smell and thromboembolism. Here we introduce a case of suspected COVID-19 induced viral myocarditis in an 86 year old woman. Case presentation: An 86-year-old female with no reported past medical history, not on daily medications, was brought in by ambulance after fall and unable to get up for many hours. On presentation, she was in mild distress due to left sided musculoskeletal pain, afebrile, tachycardic, tachypneic, and saturating at 93% on room air. Patient denied chest pain throughout her hospitalization. Tenderness in the left chest wall, left upper and lower extremities was elicited on physical examination. Labs obtained were significant for a creatine kinase of 37,000 IU/L and troponin I of 9.93ng/mL. EKG showed nonspecific T wave abnormalities, and prolonged QTC of 548ms. Chest x-ray showed multifocal pneumonia with no features suggestive of trauma. She was admitted to telemetry for further management of COVID-91 pneumonia and cardiac work up. Her troponin I peaked to 12.52ng/mL and she was treated with empiric intravenous heparin and aspirin. Echocardiogram shows global hypokinesis with left ventricular ejection fraction of 35-40%. Heart failure regimen with beta blocker and aldosterone receptor blocker were started. Rhabdomyolysis normalized with intravenous fluids. For COVID-19 pneumonia, she received dexamethasone and remdesivir and was weaned to 4L oxygen on discharge. Discussion:Viral myocarditis often results from a combination of direct viral injury and subsequent cellular immune activation. There is limited knowledge for COVID-19 associated viral myocarditis;most documented cases are from existing case reports, where most patients are male, and under the age of 70 years. Diagnosis is often challenging, as endomyocardial biopsy is often forgone in the setting of the ongoing pandemic and increased infection risk. Treatment for viral myocarditis involves heart failure management followed by directed therapy based on suspected etiology. Lymphocytic myocarditis, as seen in the setting of COVID-19, would typically involve immunosuppression in the form of glucocorticoids and intravenous immunoglobulin;although these regimens have yet to be extensively studied in COVID-19 associated myocarditis. As literature on this infection is rapidly evolving, it is vital to recognize and document suspected cases. This case helps to establish presentation of COVID-19 induced viral myocarditis and facilitate future understanding and raises awareness of this extrapulmonary presentation.