Multifactorial Effects of Covid-19: A Review of Published Autopsy Reports

Introduction: SARS-CoV-2 is responsible for the current global pandemic. SARS-CoV-2 infection underlies the novel viral condition coronavirus disease 2019 (COVID-19). COVID-19 causes significant pulmonary sequelae contributing to serious morbidities. The pathogenesis of COVID-19 is complex with a multitude of factors leading to varying levels of injury numerous extrapulmonary organs. This review of 124 published articles documenting COVID- 19 autopsies included 1,142 patients. Method(s): A PubMed search was conducted for COVID-19 autopsy reports published before March 2021 utilizing the query COVID-19 Autopsy. There was no restriction regarding age, sex, or ethnicity of the patients. Duplicate cases were excluded. Findings were listed by organ system from articles that met selection criteria. Result(s): Pulmonary pathology (72% of articles;866/1142 patients): diffuse alveolar damage (563/866), alveolar edema (251/866), hyaline membrane formation (234/866), type II pneumocyte hyperplasia (165/866), alveolar hemorrhage (164/866), and lymphocytic infiltrate (87/866). Vascular pathology (41% of articles;771/1142 patients): vascular thrombi (439/771)-microvascular predominance (294/439)-and inflammatory cell infiltrates (116/771). Cardiac pathology (41% of articles;502/1142 patients): cardiac inflammation (186/502), fibrosis (131/502), cardiomegaly (100/502), hypertrophy (100/502), and dilation (35/502). Hepatic pathology (33% of articles;407/1142 patients): steatosis (106/402) and congestion (102/402). Renal pathology (30% of articles;427/1142 patients): renal arteries arteriosclerosis (111/427), sepsis-associated acute kidney injury (81/427) and acute tubular necrosis (77/427). Conclusion(s): This review revealed anticipated pulmonary pathology, along with significant extrapulmonary involvement secondary to COVID-19, indicating widespread viral tropism throughout the human body. These diverse effects require additional comprehensive longitudinal studies to characterize short-term and long-term COVID-19 sequelae and inform COVID-19 treatment.

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background: Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Method(s): We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves;(b) reduction in T-wave amplitude by 50% in contiguous leads;(c) ST-segment depression;(d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads;(e) tall T-waves >=1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes. Result(s): Athletes were aged 22+/-5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3+/-4 days. The post COVID ECG was performed 14+/-16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID- 19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae;pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8+/-8 days v 2+/-4 days;p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3). Conclusion(s): 3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

A Practical Ambulatory Approach to Atrioventricular Block Secondary to Lyme Carditis.

Lyme carditis (LC) is a potentially reversible cause of complete atrioventricular (AV) dissociation that rarely requires a permanent pacemaker. The time to resolution is variable, sometimes requiring weeks, making a temporary permanent pacemaker (TPPM) a suitable bridge to recovery. We report on a 31-year-old man with serology-confirmed Lyme disease with complete heart block during the peak of the coronavirus disease 2019 pandemic. A TPPM was implanted and the patient was discharged the following day with regular follow-up in the ambulatory setting. Once 1:1 AV conduction was reestablished, the TPPM was removed. Our case demonstrates that the use of a TPPM for AV-dissociation secondary to LC is a safe and feasible strategy in select individuals which can minimize patient morbidity as well as hospital length of stay and overall health care costs.

Cardiac Manifestations in Pediatric COVID-19

Myocarditis is usually diagnosed clinically by electrocardiograms, echocardiography, and increased cardiac enzymes since troponin is also defined as a marker of cardiac injury in children and adolescents. Myocarditis and pericarditis have been found in up to 40% and 25% of patients, respectively. Pericardial effusion occurred in up to 32% of patients. Together with the myocardial dysfunction findings, these characterize the pancarditis associated with COVID-19. Myocardial involvement may also be related to the presence of arrhythmias. In COVID-19, hypoxia, neurohormonal or inflammatory stress, and metabolic disorders contribute to changes in the cardiac rhythm. Some of the current drug therapies used in this disease can also induce arrhythmia, adversely affecting cardiac electrophysiology. Patients with COVID-19 have an increased risk of developing venous thrombosis, reaching 25%, with the highest risk in those with increased Ddimer and inflammatory markers, decreased fibrinogen, and those with the severe acute respiratory syndrome. There is suspicion mainly in patients who develop refractory hypoxemia or asymmetric edema of the lower limbs. Coronary thrombosis, in addition to the one being characterized, may correspond to one of the pathophysiological mechanisms of cardiovascular complications. Because of the systemic inflammatory response and imbalance in the oxygen supply, there is also an increased risk of coronary ischemia.

Covid Vaccination in Children

Hazards' trade-off benefits should be considered. COVID is usually not severe in children/vs. the fact of high transmission esp. adolescence with high social communications. MISC in children may be severe. The new COVID-19 variants spread more quickly and cause more severe diseases. Millions of doses of the COVID-19 vaccine have been given, and there have only been 1,000 cases of heart inflammation. CDC: Notes that for every million doses given, there have been 67 cases of heart inflammation in boys 12 to 17 (nine in girls of that age group), 56 in those aged 18 to 24 (six in girls), and 20 in males 25 to 29 (three in girls). That means the risk is relatively low. COVID-19 can affect the heart, too - not only as part of MIS-C, a multisystem inflammatory complication of COVID-19 seen in children but also just from the infection itself. COVID-19 can cause heart damage, including myocarditis. Our only way out of this pandemic is to get as many people vaccinated as possible, including young people. Vaccinated youth can safely go to school or camp, play sports, and be with their friends and families, all of which are important for their current and future health and well-being - and all of which were curtailed during the pandemic. The FDA reviewed a study of more than 2,259 U.S. children ages 12 through 15. Of this group, about half were given the Pfizer-BioNTech COVID-19 vaccine, and the other children were given an inactive (placebo) shot. The results suggest that the vaccine is 100% effective at preventing COVID-19. In this age group, kids now make up an increasingly large share of the cases. There were at least American Academy of pediatrics 243,000 cases of COVID-19 in children from Sept 2 to Sept 9 Sept 9 in the U.S. (roughly 29% of all cases in the country).

Coronavirus vaccine and cerebral vasculitis: Potential pathophysiology

Background and Purpose: Since the implementation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, we see continued hesitancy across the world regarding the potential emergence of immune and thromboembolic complications with these injections. This has included temporary pauses over concerns for thromboembolic events and cardiac inflammation.We provide discussion of a 57-year-old patient who suffered multiple ischemic strokes, with no prior history of vascular events after receiving her SARSCoV- 2 (messenger ribonucleic acid [mRNA]) vaccination with workup suggesting CNS vasculitis in the setting of multiple positive immune markers and propose the need for further investigation in this area. Methods:Review of case presentation, testing, imaging, and laboratory studies. Results: CT angiography was performed but could not identify any vascular pathology in the large vasculature. Brain MRI/MR angiography demonstrated strokes in multiple vascular territories (similar findings on first and second admission). Conventional angiogram was completed, which also did not demonstrate large vessel abnormalities. Telemetry was unremarkable. Echocardiogram (transthoracic and transesophageal) was performed without cardioembolic source identified. Serum and CSF laboratory studies were completed and suggestive of a CNS immune process and given the overall clinical picture were most consistent with probable small vessel CNS vasculitis. Conclusion: In presenting this patient's background and medical history, which includes autoimmune hepatitis, we propose there may be a subpopulation who could be at higher risk of immune reactions in the setting of these vaccinations and that while generally still safe for the overall population, in these particular subpopulations increased caution may be warranted pending further investigation, particularly if considering the newermRNA vaccinations.

COVID-19 vaccination and carditis in children and adolescents: a systematic review and meta-analysis.

BACKGROUND: Coronavirus Disease-2019 (COVID-19) vaccination has been associated with the development of carditis, especially in children and adolescent males. However, the rates of these events in the global setting have not been explored in a systematic manner. The aim of this systematic review and meta-analysis is to investigate the rates of carditis in children and adolescents receiving COVID-19 vaccines. METHODS: PubMed, Embase and several Latin American databases were searched for studies. The number of events, and where available, at-risk populations were extracted. Rate ratios were calculated and expressed as a rate per million doses received. Subgroup analysis based on the dose administered was performed. Subjects ≤ 19 years old who developed pericarditis or myocarditis following COVID-19 vaccination were included. RESULTS: A total of 369 entries were retrieved. After screening, 39 articles were included. Our meta-analysis found that 343 patients developed carditis after the administration of 12,602,625 COVID-19 vaccination doses (pooled rate per million: 37.76; 95% confidence interval [CI] 23.57, 59.19). The rate of carditis was higher amongst male patients (pooled rate ratio: 5.04; 95% CI 1.40, 18.19) and after the second vaccination dose (pooled rate ratio: 5.60; 95% CI 1.97, 15.89). In 301 cases of carditis (281 male; mean age: 15.90 (standard deviation [SD] 1.52) years old) reported amongst the case series/reports, 261 patients were reported to have received treatment. 97.34% of the patients presented with chest pain. The common findings include ST elevation and T wave abnormalities on electrocardiography. Oedema and late gadolinium enhancement in the myocardium were frequently observed in cardiac magnetic resonance imaging (CMR). The mean length of hospital stay was 3.91 days (SD 1.75). In 298 out of 299 patients (99.67%) the carditis resolved with or without treatment. CONCLUSIONS: Carditis is a rare complication after COVID-19 vaccination across the globe, but the vast majority of episodes are self-limiting with rapid resolution of symptoms within days. Central illustration. Balancing the benefits of vaccines on COVID-19-caused carditis and post-vaccination carditis.

Medium-Term Cardiac Outcomes in Young People with Multi-system Inflammatory Syndrome: The Era of COVID-19.

Multi-system inflammatory syndrome in children (MIS-C) causes widespread inflammation including a pancarditis in the weeks following a COVID infection. As we prepare for further coronavirus surges, understanding the medium-term cardiac impacts of this condition is important for allocating healthcare resources. A retrospective single-center study of 67 consecutive patients with MIS-C was performed evaluating echocardiographic and electrocardiographic (ECG) findings to determine the point of worst cardiac dysfunction during the admission, then at intervals of 6-8 weeks and 6-8 months. Worst cardiac function occurred 6.8 ± 2.4 days after the onset of fever with mean 3D left ventricle (LV) ejection fraction (EF) 50.5 ± 9.8%. A pancarditis was typically present: 46.3% had cardiac impairment; 31.3% had pericardial effusion; 26.8% demonstrated moderate (or worse) valvar regurgitation; and 26.8% had coronary dilatation. Cardiac function normalized in all patients by 6-8 weeks (mean 3D LV EF 61.3 ± 4.4%, p < 0.001 compared to presentation). Coronary dilatation resolved in all but one patient who initially developed large aneurysms at presentation, which persisted 6 months later. ECG changes predominantly featured T-wave changes resolving at follow-up. Adverse events included need for ECMO (n = 2), death as an ECMO-related complication (n = 1), LV thrombus formation (n = 1), and subendocardial infarction (n = 1). MIS-C causes a pancarditis. In the majority, discharge from long-term follow-up can be considered as full cardiac recovery is expected by 8 weeks. The exception includes patients with medium sized aneurysms or greater as these may persist and require on-going surveillance.

Paediatric multisystem inflammatory syndrome temporally associated with COVID 19: a new virus and a new case presentation

We describe the case of an 11-year-old boy who presented with features resembling those described in health alerts on Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-COV-2 (PIMS-TS), including persistent pyrexia, haemodynamic instability and abdominal pain. His CXR showed bilateral streaky opacities. Three days prior to presentation he had an altered sense of taste, pyrexia, lethargy. Laboratory tests, including raised inflammatory markers, D-dimer, troponin and a coagulopathy were consistent with PIMS-TS. He required transfer to PICU, where he was monitored for a total of 34 h and was thereafter fit to be discharged to a paediatric ward for continuation of therapy. He was treated with intravenous immunoglobulins, corticosteroids and aspirin, with full resolution of clinical symptoms. His echocardiogram revealed mild left ventricular (LV) impairment but no evidence of coronary ectasia or valvular disfunction Microbiology and pathogenesis Three SARS-CoV-2 PCRs on respiratory samples, taken over the initial 4-day period were negative, as was a SARS-CoV-2 PCR on faeces one month after presentation;titres of IgG were clearly elevated. The negative PCRs in the presence of elevated titres of IgG suggest that the inflammatory syndrome might have developed in a late phase of COVID-19 infection when the virus was no longer detectable in the upper airway. The possibility that PIMS-TS constitutes a post-infectious syndrome cannot however be excluded. PIMS-TS pathogenesis might also be related to delayed type I and III interferon responses that lead to slow viral clearance and cytokine storm, which might fit this presentation. Outcome Following 5 days on the ward the patient was discharged home with low dose aspirin and omeprazole to be taken until otherwise advised by the cardiologist Serial follow-up echocardiograms from one to five months post-discharge were unremarkable and he has now been discharged from cardiology follow up. There have been some psychological sequelae. Learning points • Acute gastrointestinal pain in the context persistent pyrexia during the COVID-19 pandemic should lead to suspicion of PIMS-TS in children. • Cardiac inflammation is a feature of this presentation. • It appears that early treatment with immunoglobulins and intravenous steroids is helpful. • Negative SARS-CoV-2 PCR tests do not exclude COVID-19;SARS-CoV-2 IgG serology ought to be performed. • It is difficult to distinguish between acute Covid-19 and a post-acute syndrome on the basis of nasopharyngeal SARS-CoV 2 PCR alone. • More research is needed into the pathogenesis of this condition. • PCR on faeces should be considered early on, in particular in cases presenting with mainly gastrointestinal symptoms.

Pathologic Features of Post-Acute Sequelae of COVID-19 (PASC) at Autopsy

Background: Across the globe, cases of post-acute sequelae of COVID-19 (PASC) are characterized by the delayed effects of SARS-CoV-2 infection in multiple organ systems. Patients may have appeared to recover from the initial infection, but experience sequelae of the disease weeks to months later. Autopsy studies of PASC have only initially begun. Our research aims to compare the pathology of cases in which patients experienced a prolonged, progressive decline, to the cases of patients who recovered from the initial infection of SARS-CoV-2, but experienced sequelae of the condition numerous weeks to months later. Design: Autopsies were performed on 17 male and female decedents with an age range of 31-79 years with cause of death related to COVID-19 infection confirmed by SARS-CoV-2 PCR, and time between the onset of symptoms and death ranging from 30 to 112 days. Cases in which the time between the onset of symptoms and death exceeded 30 days, with evidence of initial recovery, were considered potentially PASC-related. The cases were separated into two groups based upon the timeline of first positive PCR to time of death: those who succumbed to the initial COVID-19 infection after an extended hospital course, and those with potential PASC-related disease. Clinical, gross and microscopic findings from both groups were compared, as well as PCR and IHC for SARS-CoV-2 at autopsy. Results: The most common clinical comorbidity seen in both groups was hypertension (85.7%), followed by obesity and diabetes. Common microscopic findings in the lungs included proliferative to organizing diffuse alveolar damage (DAD). Findings in PASC-related cases included extensive alveolar fibrosis, fibrosing organizing pneumonia, and thrombi within medium-sized blood vessels. Two patients in their 30s presented with vasculitis/endotheliitis involving small blood vessels of the lungs and heart, consistent with Multisystem Inflammatory Syndrome. Additionally, late thrombotic events, and cardiac inflammation including macrophage infiltration appeared to be present in cases of PASC. Immunostaining for SARS-CoV-2 nucleocapsid and PCR at the time of autopsy did not reveal a persistence of virus in cases attributed to PASC. Figure 1 - 7 Conclusions: Our findings suggest that there may be pathologic differences between a prolonged course of acute COVID-19, and PASC-related disease. Characteristics of PASC included evidence of new or continued small vessel inflammation, macrophage infiltration, and/or fibrotic disease of affected organs.

Pancarditis as the Clinical Presentation of Eosinophilic Granulomatosis with Polyangiitis: A Multimodality Approach to Diagnosis

Eosinophilic pancarditis (EP) is a rare, often unrecognized condition caused by endomyocardial infiltration of eosinophil granulocytes (referred as eosinophilic myocarditis, EM) associated with pericardial involvement. EM has a variable clinical presentation, ranging from asymptomatic cases to acute cardiogenic shock requiring mechanical circulatory support (MCS) or chronic restrictive cardiomyopathy at high risk of progression to dilated cardiomyopathy (DCM). EP is associated with high in‐hospital mortality, particularly when associated to endomyocardial thrombosis, coronary arteries vasculitis or severe left ventricular systolic dysfunction. To date, there is a lack of consensus about the optimal diagnostic algorithm and clinical management of patients with biopsy‐proven EP. The differential diagnosis includes hypersensitivity myocarditis, eosinophil granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome, parasitic infections, pregnancy‐related hypereosinophilia, malignancies, drug overdose (particularly clozapine) and Omenn syndrome (OMIM 603554). To our knowledge, we report the first case of pancarditis associated to eosinophilic granulomatosis with polyangiitis (EGPA) with negative anti‐neutrophil cytoplasmic antibodies (ANCA). Treatment with steroids and azathioprine was promptly started. Six months later, the patient developed a relapse: treatment with subcutaneous mepolizumab was added on the top of standard therapy, with prompt disease activity remission. This case highlights the role of a multimodality approach for the diagnosis of cardiac involvement associated to systemic immune disorders.

A Comparative Analysis of COVID-19 Vaccines Based on over 580,000 Cases from the Vaccination Adverse Event Reporting System.

BACKGROUND: The COVID-19 pandemic is being battled via the largest vaccination campaign in history, with more than eight billion doses administered thus far. Therefore, discussions about potentially adverse reactions, and broader safety concerns, are critical. The U.S. Vaccination Adverse Event Reporting System (VAERS) has recorded vaccination side effects for over 30 years. About 580,000 events have been filed for COVID-19 thus far, primarily for the Johnson & Johnson (New Jersey, USA), Pfizer/BioNTech (Mainz, Germany), and Moderna (Cambridge, USA) vaccines. METHODS: Using available databases, we evaluated these three vaccines in terms of the occurrence of four generally-noticed adverse reactions-namely, cerebral venous sinus thrombosis, Guillain-Barré syndrome (a severe paralytic neuropathy), myocarditis, and pericarditis. Our statistical analysis also included a calculation of odds ratios (ORs) based on total vaccination numbers, accounting for incidence rates in the general population. RESULTS: ORs for a number of adverse events and patient groups were (largely) increased, most notably for the occurrence of cerebral venous sinus thrombosis after vaccination with the Johnson & Johnson vaccine. The overall population OR of 10 increases to 12.5 when limited to women, and further yet (to 14.4) among women below age 50 yrs. In addition, elevated risks were found (i) for Guillain-Barré syndrome (OR of 11.6) and (ii) for myocarditis/pericarditis (ORs of 5.3/4.1, respectively) among young men (<25 yrs) vaccinated with the Pfizer/BioNTech vaccine. CONCLUSIONS: Any conclusions from such a retrospective, real-world data analysis must be drawn cautiously, and should be confirmed by prospective double-blinded clinical trials. In addition, we emphasize that the adverse events reported here are not specific side effects of COVID vaccines, and the significant, well-established benefits of COVID-19 vaccination outweigh the potential complications surveyed here.

Multisystem inflammatory syndrome in children associated with SARS-COV-2 and Kawasaki disease: experience of pediatric clinics in Russia

Introduction: COVID-19 in children is often asymptomatic or with only mild symptoms. However, since April 2020 there are many reports that the new coronavirus infection might be associated with pediatric hyperinflammatory condition, that fully or partially meets the criteria for Kawasaki disease (KD). This phenomenon was later called multisystem inflammatory syndrome in children (MIS-C) or pediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV-2 (PIMS-TS). Objectives: Our study aimed to evaluate main clinical and laboratorial features and course of MIS-C and compare it with Kawasaki disease in children. Methods: The retrospective study included 50 children (34 male, 16 female), aged from 7 months to 16 years 9 months (median 8.8 years), who met the WHO criteria for MIS-C and 60 patients (34 male, 26 female, aged from 3 months to 6 years (median 2 years) with Kawasaki disease. Results: Prior COVID-19 infection in MIS-C group was confirmed by positive SARS-CoV2 test using RT-PCR (n=11) or IgM (n=21), IgG (n= 38) and/or close contact with a person with confirmed COVID-19 (n= 21) clinical features of previous COVID-19 infection were noted in 22 patients. Clinical sings of MIS-C included fever (100%), gastrointestinal disorders (81.6%), rash (90%), conjunctivitis (93.6%), sore throat (68.1%) cheilitis (54.6%), cervical lymphadenopathy (68.2%), hands and feet erythema/oedema (69.8%), hepathomegaly (64.6%). In the majority of patients elevated levels of inflammatory biomarkers, D-dimer, troponin, ferritin were found. Most of patients had a tendency to anemia (median hemoglobin 105 g/l). Platelet levels varied greatly (8-919∗109/l), 37.5% of patients had thrombocytopenia. Carditis and coronary artery dilatation were found in 48.9% and 22.7%, respectively. Arterial hypotension/shock was in 52.5%. Heart MRI showed signs of myocarditis (n=5): T1 prolongation (n=2);signs of myocardial edema, pericarditis, severe arrhythmia, and a tendency to diastolic overload (n=1), but no signs of ischemic or non-ischemic myocardial damage, and the global systolic function stayed normal. Patients were treated with high-dose glucocorticoids (93.6%), low-weighted heparin (100%), low dose of aspirin (64.4%), intravenous immunoglobulin (37.8%);Tocilizumab was used in three patients (6%). The median duration of hospitalization was 22 days, and 65.9% of patients required an ICU admission. Some of the most informative indicators for the differential diagnosis of MIS-C and KD are shown in the table. Conclusion: MIS-C is severe life-threatening condition in children, which pathogenesis and relation to COVID-19 requires further research. There are differences in the frequency of some signs that possibly can be used as a basis for differential diagnosis of the studied conditions.

A curious case of Lyme carditis in an urban hospital.

Lyme carditis (LC), a manifestation of early disseminated Lyme disease, most commonly presents with cardiac conduction abnormalities. It is a transient condition with good prognosis but in extremely rare cases may be life-threatening. We describe a 42-year-old man who presented with progressively worsening generalized weakness, presyncope and dyspnea on exertion for 2 weeks after sustaining a tick bite. He subsequently developed a 'bull's eye rash' on his flank 2 days before his presentation. He was found to have symptomatic third-degree AV conduction blockade with a ventricular escape rhythm resulting in a brief cardiac arrest. Intravenous (IV) ceftriaxone was commenced empirically and a temporary transvenous pacemaker was placed. In a few days he showed dramatic, rapid improvement; the pacemaker was removed, and the patient was discharged on oral doxycycline to complete a 24-day course. This case is unique due to its occurrence in an urban hospital where such cases are uncommon. Cardiac arrest, although brief in this case, is a rare occurrence. Lyme carditis was a surprise diagnosis in our hospital due to the patient's geographical dislocation during the COVID-19 pandemic.

COVID-19 and the heart: what we have learnt so far.

Since the outbreak of COVID-19 or coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 from Wuhan, China, the cardiology fraternity's interest has been drawn towards the pandemic with a high case fatality rate of 10.5% and 6% in patients with heart disease and hypertension, respectively. One of the postulated mechanisms for this high fatality rate is the possible abundance of ACE type 2 receptor in the cardiovascular system that strongly binds with the spike protein of COVID-19 and helps internalise into the cell resulting in acute cardiac injury (ACI). More than 7% of cases with COVID-19 are reported to have this type of ACI. A tenfold rise in mortality has been observed in patients with COVID-19 who experience a rise in high-sensitivity (hs)-troponin. All most half of the patients who died of COVID-19 had a rise in hs-troponin. More than 15% of cases with COVID-19 experienced different types of arrhythmias. All these statistics denote how important cardiovascular pathology is in patients with COVID-19. Controversies of renin-angiotensin-aldosterone system inhibitors usage in patients with COVID-19 and meticulous handling of case with acute coronary syndrome categorically stresses cardiologists to bust the myths hovering around and set a standard guideline to counterfeit the fatality with timely diagnosis and treatment of COVID-19-induced ACI. In this review, we sought to summarise the current evidence of COVID-19-associated cardiac injury and suggest the implications for its proper diagnosis and treatment.