Angela Li, MD
Cardiologist
North Shore University Hospital, United States
Disclosure information not submitted.
Rajiv Jauhar, MD
Interventional Cardiologist, Chief of Cardiology
North Shore University Hospital, United States
Disclosure information not submitted.
Suresh Jain, MD
Cardiologist, Interventional Cardiology
Lenox Hill Hospital, United States
Disclosure information not submitted.
Title: Acute fulminant myocarditis associated with COVID-19 Multisystem Inflammatory Syndrome in Adults
Case Report Body:
Introduction: COVID-19 is known to be a cause of myocarditis, both in the acute phase and as part of the delayed multisystem inflammatory syndrome in adults (MIS-A). The time to onset of symptoms is variable and can present in patients with a positive test or during the late convalescent stage. Fulminant myocarditis occurs quickly and leads to severe heart failure or circulatory failure, with 50-70% mortality rates. Hence early identification and initiating appropriate treatment is crucial for survival. We present a case of fulminant myocarditis in a young patient as a part of COVID-19 MIS-A.
Description: A 21-year-old male with no prior medical history presented with five days of fevers, chills, headaches, abdominal pain and myalgia. Social history was significant for high-risk sexual activity without alcohol and drug use. He had a week-long trip to Nigeria. He was started on intravenous fluids for presumed sepsis but developed respiratory distress and chest pain with worsening tachycardia. CT pulmonary angiogram was negative. Echocardiogram showed global hypokinesia with severely reduced ventricular systolic function. He continued to have chest pain, rising troponin and worsening hypotension despite initiation of norepinephrine and broad-spectrum antibiotics. Given concern for cardiogenic shock, he was started on dobutamine. His condition deteriorated requiring intubation and mechanical ventilation. Infectious workup remained negative with the exception of COVID-19 nucleocapsid antibody indicative of past infection. After consultation with infectious disease, methylprednisolone and intravenous immunoglobulin were started for possible MIS-A. He responded rapidly to treatment and could be weaned off of inotropic support and extubated. A repeat echo showed recovery of cardiac function. He was discharged with a plan to follow up with cardiac MRI.
Discussion: MIS-A involves the gastrointestinal tract, kidney and reticuloendothelial system. Few reported to have cardiac involvement. It is still unclear whether myocarditis is an indirect complication or direct cardiac manifestation of the virus. Diagnosis is based on EKG and cardiac biomarkers and when there is low likelihood of acute coronary syndrome. We emphasize the importance of multidisciplinary care and early recognition of the syndrome and order antibody testing.