Stephen Mitchell
Resident
Atrium Health
Charlotte, North Carolina
Disclosure information not submitted.
John Symanski, MD
Cardiology - Attending Physician
Carolinas Medical Center - Atrium Health, United States
Disclosure information not submitted.
Title: Fulminant Lymphocytic Myocarditis: Broadening Our Differential at the Onset of the COVID-19 Pandemic Case
Introduction: During the early phases of the COVID-19 pandemic, providers were faced with a myriad of diagnostic challenges as they sought to understand the sequelae of SARS-CoV-2 infections. One complication we observed to increase in prevalence was fulminant myocarditis (FM). FM is a rare syndrome characterized by severe and sudden diffuse inflammation of the myocardium, often leading to ventricular arrhythmias, cardiogenic shock, or multisystem organ failure.
Description: A 68 year-old female with history of ovarian cancer and hypothyroidism, presented with four day history of vomiting, headache, and fever. Patient reportedly had a negative rapid COVID-19 test three days prior to presentation but symptoms persisted. On arrival, patient was febrile and tachycardic. She denied shortness of breath or cough. CT chest was unremarkable. No EKG was obtained. COVID testing was repeated prior to discharge. Patient re-presented the next day with persistent high fever, vomiting, and fatigue. EKG indicated tachycardia and complete heart block along with ST segment elevations in V1, V2 and aVL with reciprocal ST depression. Laboratory work-up indicated significantly elevated troponin and BNP. Signs of end organ damage noted with elevated transaminases, lactate and impaired renal function. Patient was urgently taken to cath lab. Right heart catheterization indicated elevated filling pressures and severely reduced cardiac output. Coronary angiography indicated normal appearing coronary arteries without obstructive disease. Echocardiogram was notable for non-dilated ventricles with mildly increased wall thickness and globally Reduced systolic function. Impella and temporary pacemaker placed. Patient admitted with findings suggestive of acute myocarditis, with COVID infection being the leading candidate. Lengthy deliberation held prior to cannulation for VA ECMO given patient’s advanced age, suspicion for COVID, and limited availability of this intervention. Complete viral work-up including COVID ab, was negative and RV biopsy indicated lymphocytic myocarditis. Patient achieved full cardiac recovery after a complicated hospital course.
Discussion: We highlight this case of FM early in the COVID-19 pandemic where the high suspicion for COVID infection lead to both a delay in diagnosis and serious deliberations about use of ECMO.