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Case Report – Myocardial localization of coronavirus in COVID‐19 cardiogenic shock

Key Points:

Tavazzi G, Pellegrini C, Maurelli M, et. al. EJHF: https://doi.org/10.1002/ejhf.1828

 

Case report – First Documented, Biopsy proven, Myocarditis with Coronavirus Involvement

  • Flu-like symptoms become acute respiratory failure complicated by Shock with reduced Left Ventricular Ejection Fraction (LVEF) (25%) with lymphopenia and leukocytosis and positive inflammatory markers and cardiac markers (hs‐TnI-4332 ng/L).
  • Mechanical ventilation, IABP and V-A ECMO were instituted for hemodynamic and respiratory support.
  • Coronary Angiography was non-diagnostic and Endomyocardial Biopsy pathology demonstrated low‐grade myocardial inflammation with an absence of myocyte necrosis. Coronavirus particles were found in macrophages and interstitial cells but viral particles were not definitively identified in cardiac myocytes.
  • Cardiac function recovered by day 5 and ECMO and IABP were removed
  • On day 13, the patient acutely developed Gram-negative sepsis without cardiac decompensation and died of septic shock.
  • Interpretation of the Biopsy findings
  • While the clinical presentation was consistent with an acute necrotizing, inflammatory myocarditis, the pathology demonstrated only mild inflammation without necrosis. Viral particles were found in the lungs and based on prior viral illnesses (MERS‐CoV), viral particles frequently appear in other organs. However, no vascular involvement was observed.
  • The authors hypothesize that cardiac involvement occurred secondary to a viremia or by an extra-pulmonary transfer of virus via macrophages into the myocardium.
  • This is a single case. More are needed to confirm and add to these findings, but the current case illustrates an early viral involvement with a likely later inflammatory response that can lead to large cytokine release.
  • Hemodynamic and respiratory support potentially with Interleukin treatment may reduce the severity of the illness

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