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Background Cardiogenic shock is a rare complication of influenza myocarditis and multisystem inflammatory syndrome. We present the case of a 32-year-old female in cardiogenic shock who met criteria for both entities. Case A 34-year-old female with hypothyroidism presented after being found down and covered in feces. She had cough and weakness the preceding days. She was febrile and hypotensive. Point of care ultrasound showed severe biventricular dysfunction and she was started on norepinephrine. She was influenza A positive with a lactate of 5.1. Right heart catheterization on 2ug/kg/min of norepinephrine showed a cardiac index (CI) of 2.82 L/min/m2 and a systemic vascular resistance (SVR) of 300 dynes/sec/cm-5. She was started on vasopressin, stress dose steroids, and oseltamivir. She received 6 amps of bicarbonate with aggressive electrolyte repletion. CI as per the Fick equation was within normal limits but lactate continued to rise. Thermodilution showed a CI of 1.6 L/min/m2 and an SVR of 2200 dynes/sec/cm-5, indicating mixed cardiogenic and distributive shock. The patient developed severe abdominal pain and was found to have elevated COVID-19 spike domain and nucleocapsid antibodies, meeting criteria for multisystem inflammatory syndrome (MIS-A). Decision-making The patient was started on dobutamine after thermodilution showed decreased CI. Intravenous immunoglobulin was started after meeting criteria for MIS-A. Her pressor requirements were weaned and then her dobutamine requirements. Follow up cardiac MRI showed mild global hypokinesis of the left ventricle and subtle hypokinesis of the right ventricular inferior wall. Left ventricular ejection fraction was 51%. The patient's cardiac MRI findings were not specific. However, her rapid improvement was suggestive of MIS-A. Additionally, consistent discordance between Fick and thermodilution resulted in confusion regarding optimization of pressors and inotropes. Conclusion The patient responded to dobutamine and MIS-A treatment after an initial impression of myocarditis. Infectious processes should be considered in any patient with new onset heart failure.Copyright © 2023 American College of Cardiology Foundation
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Clinical data and follow-up of a case of congenital disorder of glycosylation type Ia (CDG-Ia) combined with dilated cardiomyopathy admitted to the Department of Cardiology, Children's Hospital of Nanjing Medical University were analyzed retrospectively.The 5-year-old female patient was admitted in December 2016 due to recu-rrent shortness of breath for 2 months.Clinical symptoms and signs included repeated attacks of shortness of breath, physical retardation, malnutrition, binocular esotropia, multiple episodes of hypoglycemia, hepatosplenomegaly, hypotonia and other multi-system damages.Cardiac echocardiography suggested the feature of dilated cardiomyopathy, including the significant enlargement of the left ventricle, and decreased systolic function.Genetic testing revealed a compound heterozygous mutation in the PMM2 gene, and as a result, the patient was diagnosed as CDG-Ia.The patient's condition improved after symptomatic treatments such as Cedilanid, Dopamine, Dobutamine, Furosemide, as well as support treatments like myocardium nutrition, blood sugar maintenance, liver protection, etc.After discharge, the patient was given oral Digoxin, Betaloc, Captopril and diuretics, and hypoglycemia-controlling agents.The patient was followed up every 3-6 months.After more than 2 years of follow-up, the heart function and heart enlargement gradually returned to normal.During the Corona Virus Disease 2019 outbreak, self-withdrawal continued for 2 months.Re-examinations showed decreased cardiac function and enlarged left ventricle again.Medications were resumed again, and the patient was followed up closely.This case report suggested that CDG-Ia may be associated with dilated cardiomyopathy, and the cardiac phenotype may be improved by symptomatic supportive treatment.Copyright © 2021 by the Chinese Medical Association.
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Background Human granulocytic anaplasmosis (HGA) is a tick-borne disease caused by Anaplasma phagocytophilum. The most common presenting features are transaminitis, leukopenia, thrombocytopenia, fever, and malaise. HGA causing cardiomyopathy likely from myocarditis is uncommon but a serious complication. Case A 70 year-old male with a history of coronary artery disease presented with fever (38.3 C) and dyspnea on exertion. He was found to have hypoxic respiratory failure, pancytopenia, acute kidney injury and transaminitis. He was treated empirically with ceftriaxone and doxycline. Baseline electrocardiogram was unremarkable for ischemia. However, he had troponin elevation and was decompensated on exam. Bedside transthoracic echocardiogram (TTE) showed LVEF of 20-25% for which he was administered dobutamine and monitored in intensive care unit (ICU). Repeat TTE illustrated LVEF 30-35% with moderate diffuse hypokinesis of LV. Blood and urine cultures were negative. He tested positive for Anaplasma DNA-PCR with unremarkable rest of the tick borne, viral and parasitic panel. He was then continued with doxycycline for 14 days for sepsis due to Anaplasmosis. Follow up TTE in a month showed improved LVEF to 40% with resolution of his symptoms. Decision-making Our patient presented with common tick-borne illness symptoms and signs, which prompted initiation of empiric antibiotics. However, the significantly reduced LVEF and elevated troponins were concerning for which he was monitored in ICU. Cardiac magnetic resonance imaging was not pursued due to delay in transfer process to the higher center amidst COVID pandemic and ongoing sepsis due to Anaplasmosis. After the results of HGA PCR, he was continued on a 14-day course of doxycycline which eventually resolved his symptoms. Conclusion There must be a high level of suspicion for cardiomyopathy if the patient is being empirically treated for tick-borne illness and has decompensated heart failure symptoms. PCR is the most sensitive test for diagnosing HGA. However, the test results should not delay the treatment as tick-borne illness responds well to doxycycline which should alleviate the heart failure symptoms as seen in our case.Copyright © 2023 American College of Cardiology Foundation
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Background: Multisystem inflammatory syndrome in children (MIS-C), causing high morbidity and mortality, is the hyperinflammatory response following COVID-19 infection (CI). According to the MISC management guideline, Anakinra (anti-IL1) is the preferable agent among other biologic agents: Infliximab, Tocilizumab (TCZ), and baricitinib if the patient is refractory to intravenous immunoglobulin (IVIG) and systemic corticosteroid (CS). However, these are not available in a number of countries, including Thailand. Our case represents refractory MIS-C in a systemic juvenile idiopathic arthritis (SJIA) patient responding well to TCZ. Method(s): Diagnostic investigations, including basic and immunological blood tests, and echocardiography assessment, were conducted. Result(s): A 12-year- old boy has been diagnosed with SJIA since he was 2 years old, according to the presentation of prolonged fever, hepatomegaly, and evanescent rash. CS, cyclosporin-a, and TCZ have been prescribed, and he has been in clinical remission off medication for two years. He experienced acute fever, rash, shortness of breath, nausea and vomiting for few days. Physical examination revealed a febrile boy with respiratory failure, compensated shock, and a generalized persistent maculopapular rash. The other was unremarkable. MIS-C was one of the possible diagnoses according to fever accompanied by more than two systems involved and his previous CI four weeks prior. Laboratory investigation revealed an elevated inflammatory response (Figure 1). The echocardiography was done by an experienced cardiologist with concern for myocardial dysfunction in MIS-C and showed a significant poor ejection fraction of the left ventricle of 42% under dobutamine, milrinone, and norepinephrine. Broad spectrum antibiotics and IVIG (1 g/kg/dose for two days) were initiated. After hemoculture did not report bacteria growth, pulse intravenous methylprednisolone (IVMP) 1000 mg for 3 days was given for the MIS-C treatment. After initial aggressive treatment with IVIG and pulse IVMP, the patient still has a high grade fever with laboratory revealed ongoing elevated inflammatory markers. The other possible causes of fever, such as infection and active SJIA were suspected. Immunological profiles returned with positive SAR-COV2 IgG, negative SAR-COV2 IgM, which confirmed the diagnosis of MIS-C with refractory to IVIG and CS. After multidisciplinary team discussion, TCZ was given. He had neither fever, dyspnea, nor heart failure. His clinical condition gradually improves together with laboratory parameters (Figure 1). Conclusion(s): In conclusion, our case demonstrated TCZ as a potential therapeutic agent in refractory MIS-C patients living in countries with limited access to anti-IL1 agents. The multidisciplinary care team together with prompt management is advisable to the best benefit of the patient. (Figure Presented).
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SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory condition characterized by fever, elevated inflammatory markers, and multi-organ dysfunction, including severe cardiac illness, neurological and gastrointestinal symptoms, mucocutaneous involvement, and thrombocytopenia usually 2-5 weeks after COVID-19 infection (1). There are currently no guidelines for the management of this novel syndrome. CASE PRESENTATION: A 20-year-old obese male presented for 3 days of fatigue, fever, dyspnea, diarrhea, and worsening encephalopathy. He tested positive for COVID-19 3 weeks prior and experienced 4 days of mild symptoms. He had received 2 doses of Moderna mRNA vaccine 9 months prior. On presentation, he had a GCS of 3. He was febrile, hypotensive, tachycardic, not hypoxic, and found to have non-purulent conjunctivitis but no rash. He was intubated for airway protection and started on norepinephrine (NE) shortly after arrival. Labs revealed positive COVID-19 PCR, lactate of 5.6 mmol/L, elevated hs-troponin which peaked at 11,300 ng/L, D-Dimer 12,574 ng/ml, ferritin >16,500 ng/ml, CRP 224 mg/L, platelet count 18 x109/L. EKG showed sinus tachycardia without ST changes. CT chest/abdomen/pelvis was unremarkable. The patient was given broad-spectrum antibiotics and admitted to ICU. An echocardiogram (echo) showed global hypokinesis with an ejection fraction of 10-15%. Right heart catheterization found a wedge pressure of 23 mmHg, and a cardiac index of 1.4 L/min/m2. NE was weaned, and dobutamine and bumetanide drips were started. Infectious disease was consulted and diagnosed the patient with MIS-A. Treatment was started with methylprednisolone 2mg/kg/day and IVIG (2 g/kg x2 days). 48 hours later, dobutamine was able to be discontinued and follow-up echo showed normalization of biventricular systolic function. Steroids were continued for 7 days before tapering off. The patient’s presenting symptoms, platelets, and inflammatory markers rapidly improved, and he was ultimately able to be discharged home. DISCUSSION: MIS-A is a rare but serious extrapulmonary sequela of COVID-19 which can cause critical illness including cardiogenic shock. The long-term consequences of MIS-A are not known, but fortunately, as demonstrated by our case, severe cardiac dysfunction can be effectively reversed with timely diagnosis and initiation of immunosuppressive treatment. This recovery was achieved without immunomodulators (eg tocilizumab) which have been used in other MIS-A cases (2). MIS-A should be considered in patients with severe cardiac dysfunction and evidence of systemic inflammation even with no known history of COVID as this can develop after mild or even asymptomatic COVID-19 infections. CONCLUSIONS: Immunosuppressive therapies can rapidly reverse severe multiorgan dysfunction in MIS-A. Still, further study is needed to identify at-risk patients and create definitive treatment guidelines. Reference #1: Vogel TP, Top KA, Karatzios C, et al. Multisystem inflammatory syndrome in children and adults (MIS-C/A): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2021;39(22):3037-3049. doi:10.1016/j.vaccine.2021.01.054 Reference #2: Patel P, DeCuir J, Abrams J, Campbell AP, Godfred-Cato S, Belay ED. Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review. JAMA Netw Open. 2021;4(9):e2126456. doi:10.1001/jamanetworkopen.2021.26456 DISCLOSURES: No relevant relationships by Christopher Allison no disclosure on file for Sandeep Arepally;No relevant relationships by Amad Chohan No relevant relationships by Albert Manudhane No relevant relationships by Griffin Reed
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Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can involve children of all ages, although less frequently and with a milder presentation than adults. Cardiovascular abnormalities (myocardial injury, acute myocarditis, cardiomyopathy, heart failure, arrhythmias, pericarditis, cardiogenic shock, pulmonary embolism, myocardial infarction) may accompany, especially with the multisystem inflammatory syndrome in children and adolescents (MIS-C). Severe disease is managed in the hospital setting. Supportive care is the mainstay of therapy. Antiviral therapy, immune-mediated therapies, empiric antibiotics, and therapy for influenza infection are used in selective patients. Cardiac management focuses on maintaining hemodynamic stability and providing adequate systemic perfusion. Children presenting with shock should be resurrected according to standard protocols. Vasoactive agents such as epinephrine or norepinephrine and, if possible, milrinone is used in fluid-refractory shock. Children with Kawasaki disease (KD) features should receive standard therapies for KD, including intravenous immune globulin (IVIG), aspirin, and glucocorticoids. Patients with severe LV dysfunction, intravenous diuretics and inotropic agents, such as milrinone, dopamine, and dobutamine are suggested. Continuous cardiac monitoring is essential. In cases of the fulminant disease, mechanical hemodynamic support may be necessary. For moderate or severe manifestations (shock, left ventricular systolic dysfunction, elevated troponin or brain natriuretic peptide, arrhythmia, coronary artery aneurysm, or presentations requiring PICU care), therapy with combined IVIG plus a glucocorticoid is suggested. Patients may be at risk for venous thromboembolism due to COVID- 19 associated hypercoagulability. Patients with MIS-C and those with severe LV dysfunction or CA aneurysms are at increased risk. It is suggested that all patients with MIS-C receive low-dose aspirin, and severe cases requiring PICU care receive prophylactic-dose anticoagulant therapy. Patients with current or prior VTE, severe LV dysfunction, large or giant CA aneurysms, markedly elevated D-dimer should receive therapeutic anticoagulation (low molecular weight heparin) plus aspirin. Most children with cardiac involvement have recovery of function by hospital discharge. The overall mortality rate for MIS-C is approximately 1 to 2 percent. Cardiology follow-up after discharge is recommended.
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Background: It is crucial to differentiate patients affected by COVID-19 from others who only tested positive to SARS-CoV-2 to optimize the treatments. We need to identify respiratory symptoms unrelated to SARS-CoV-2 infection. We report a case of severe cardiogenic dyspnea in a patient admitted for COVID-19. Case Report: A 79-year-old woman with nasal swab positive for SARS-CoV-2 was admitted for dyspnea and asthenia for 2 weeks. At the admission she presented with orthopnea, ankles swelling and oliguria. EKG showed atrial fibrillation and echocardiogram showed diffuse left ventricle hypokinesia, severe reduced ejection fraction, right ventricle normal dimensions and kinesia, not very modular inferior venae cavae, negative femoro popliteal CUS, absence of pericardial effusion, diffuse and homogeneous thoracic pattern B. She started furosemide and dobutamine with strict clinical and ultrasound monitoring. Because of the reduction of dyspnea and an incremented diuresis, dobutamine was stopped in the second day. On day 3 there was a worsening, echocardiogram showing a severe aortic stenosis, very small inferior venae cavea. Liquid infusion was started with caution to increase preload. Once obtained hemodynamic stabilization, the patient underwent coronary angiography. No coronary lesions were found and TAVI was performed successfully. Conclusions: The patient experimented respiratory symptoms due to acute heart failure. Dobutamine infusion made manifest a preexisting severe aortic stenosis that was successfully treated.
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Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies. Some patients with a hyperglycemic crisis can present with an overlap of DKA and HHS. The coexistence of DKA and HHS is associated with higher mortality than in isolated DKA and HHS. In addition, electrolyte derangements caused by global electrolyte imbalance are associated with potentially life-threatening complications. Here, we describe three cases of mixed DKA and HHS with severe hypernatremia at the onset of type 2 diabetes mellitus. All patients had extreme hyperglycemia and hyperosmolarity with acidosis at the onset of diabetes mellitus. They consumed 2 to 3 L/d of high-carbohydrate drinks prior to admission to relieve thirst. They showed severe hypernatremia with renal impairment. Two patients recovered completely without any complications, while one died. Severe hypernatremia with mixed DKA and HHS is rare. However, it may be associated with excess carbohydrate beverage consumption. Reduced physical activity during the COVID19 pandemic and unhealthy eating behaviors worsened the initial presentation of diabetes mellitus. We highlight the impact of lifestyle factors on mixed DKA and HHS.
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Introduction: The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease. Purpose: To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital. Methods: We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019. Results: Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2). Conclusions: Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic.
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Introduction: Timeliness of diagnosis and treatment of MIS-C has increased amid the COVID-19 pandemic. Methods: A child was admitted to our clinic (male, 14 years old). He was in contact with a COVID-19 patient 17 days before. Upon admission, the patient complained of a rise in body temperature to 40° C, abdominal pain, vomiting, and diarrhea. Hemorrhagic rash on the skin of the upper and lower extremities, hyperemia of the mucous membrane of the lips and tongue, arterial hypotension were found. Hospitalized at ICU. In laboratory tests: WBC 3.42 × 109/ l, RBC 4 × 1012/ l, HB 111 g/l, HTC 31, PLT 31 × 109/ l, CRP 283 mg/l, PCT 6.66, D-dimer 9.2, LDG 194 U/l, ferritin 989 mcg/l, ALT 54 U/l, GGT 79 IU/l, albumin 32 g/l;proteinuria 0.75 g\l, hematuria. Diagnosis: MIS-C associated with COVID-19. Results: Prescribed: Meropenem 20 mg/kg/d, methylprednisolone 2 mg/kg/d. After 8 h-septic shock. 0.3 μg/kg/min norepinephrine was started. ECG-a violation of repolarization with ST elevation up to 0.3 mm. Echocardiography-a decrease in the left ventricular ejection fraction to 47%, pericardial effusion. Ultrasound examination of the abdominal cavity: hepatosplenomegaly. Dobutamine 3 μg/kg/min was added to the therapy. An increase in PCT up to 19.8 was found. IV IgG 2 g/kg was added to the therapy. On the 3rd day of therapy, regression of all symptoms was obtained. On the 8th day, the child was transferred from the ICU to the pediatric department. On the 12th day he was discharged home. Conclusions: Thus, the timely diagnosis of MIS-C associated with COVID-19 and the appointment of intensive therapy with the inclusion of methylprednisolone and IV IgG allows achieving a positive result in the shortest possible time. Consent to Publish: Written informed consent was obtained from the next of kin.
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Background: COVID-19 has documented multisystem effects. Whether clinically significant cardiac involvement is related to severity of disease in a working age military population remains unknown, but has implications for occupational grading and ability to deploy. Aims: To determine in the military population 1) whether prior SARS-CoV-2 infection causes clinically significant cardiac disease and 2) whether changes are related to disease severity. Methods: 105 military personnel were recruited, 85 with prior SARS-CoV-2 infection (39±10 years, 87% male;50 mild (community), 35 severe (hospitalized) and 20 healthy volunteers (mean age 39 ±8.4 years, 90% male) underwent comprehensive cardiopulmonary investigations including;cardiopulmonary exercise test, exercise echocardiography, cardiac31MRI and P-MR spectroscopy (rest and dobutamine stress). Results: Prior SARS-CoV-2 infection was related to lower VO2max (110±18.2 vs 133±6.7% predicted, p<0.05), anaerobic threshold (45±10 vs 56±14% of peak VO2, p<0.05), VO2/HR (102±21 vs 128±24% predicted, p<0.05) and VE/VCO2 slope (28.3±5.0 vs 25.8±2.7, p<0.05) and an increase in average E/e' change from rest to exercise stress (+1.49±2.4 vs-0.16±3.6, p<0.05). Whilst resting myocardial energetics were similar, prior SARS-CoV-2 infection was associated with a fall in PCr/ATP during stress (by 8%, p=<0.01) which was not seen in healthy controls. When groups were ordered normal> mild> severe disease, RVEDVi, RV stroke volume, VO2peak, VO2pulse and VE/VCO slope were reduced (Jonckheere-Terpstra, all p<0.05). Conclusion: In a young military population, prior SARS-CoV-2 infection is associated with subclinical cardiovascular changes including;lower right ventricular volumes, reduced markers of exercise capacity and reduced myocardial energetics during stress.
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Global health is under heavy threat by a worldwide pandemic caused by a new type of coronavirus (COVID-19) since its rapid spread in China in 2019 [1]. Currently, there are no approved specific drugs and effective treatment for COVID-19 infection, but several available drugs are known to facilitate tentative treatment. Since drug design, development and testing procedures are time-consuming [2], [1], [2], [3], virtual screening studies with the aid of available drug databases take the initiative at this point and save the time. Besides, drug repurposing strategies promises to identify new agents for the novel diseases in a time-critical fashion. In this study, we used structure based virtual screening method on FDA approved drugs and compounds in clinical trials. As a result of this study we choose three most prominent compounds for further studies. Here we show that these three compounds (dobutamine and its two derivatives) can be considered as promising inhibitors for SARS-CoV-2 main protease and results also demonstrate the possible interactions of dobutamine and its derivatives with SARS-CoV-2 main protease (6W63) [6]. Our efforts in this work directly address current urgency of a new drug discovery against COVID-19.