Role of telemedicine in anesthesia: Are we ready yet?

Telemedicine is a modality which utilizes technology to provide and support health care across large distances. It has redefined the practices of medicine in many specialties and continues to be a boon for clinicians on many frontiers. Its role in the branch of anesthesia remains largely unexplored but has shown to be beneficial in all the three phases: pre-operative, intra-operative, and post-operative. Now time has come that anesthesiologists across the globe reassess their strategies and utilize the telemedicine facilities in the field of anesthesia.Copyright © 2021 EDP Sciences. All rights reserved.

Review on the Advancements of Stethoscope Types in Chest Auscultation.

Stethoscopes were originally designed for the auscultation of a patient's chest for the purpose of listening to lung and heart sounds. These aid medical professionals in their evaluation of the cardiovascular and respiratory systems, as well as in other applications, such as listening to bowel sounds in the gastrointestinal system or assessing for vascular bruits. Listening to internal sounds during chest auscultation aids healthcare professionals in their diagnosis of a patient's illness. We performed an extensive literature review on the currently available stethoscopes specifically for use in chest auscultation. By understanding the specificities of the different stethoscopes available, healthcare professionals can capitalize on their beneficial features, to serve both clinical and educational purposes. Additionally, the ongoing COVID-19 pandemic has also highlighted the unique application of digital stethoscopes for telemedicine. Thus, the advantages and limitations of digital stethoscopes are reviewed. Lastly, to determine the best available stethoscopes in the healthcare industry, this literature review explored various benchmarking methods that can be used to identify areas of improvement for existing stethoscopes, as well as to serve as a standard for the general comparison of stethoscope quality. The potential use of digital stethoscopes for telemedicine amidst ongoing technological advancements in wearable sensors and modern communication facilities such as 5G are also discussed. Based on the ongoing trend in advancements in wearable technology, telemedicine, and smart hospitals, understanding the benefits and limitations of the digital stethoscope is an essential consideration for potential equipment deployment, especially during the height of the current COVID-19 pandemic and, more importantly, for future healthcare crises when human and resource mobility is restricted.

A Cost-effective, Patient-facing Electronic Stethoscope For Telemedical Cardiac Auscultation

Introduction: The COVID19 pandemic spurred an unprecedented growth in telehealth utilization across medical specialties which challenged providers to adapt their standard history and physical protocols for the virtual realm. Heart failure clinicians could readily translate some aspects of physical examination such as jugular venous distention and lower extremity edema assessment over video incorporating bendopnea to gain additional information. However, objective data for clinicians to rely on and guide therapy was often missing. A myriad of technology is available to bridge this gap ranging from simple wearables to invasive hemodynamic monitors though come with varying price tags and avenues of accessibility. Objective(s): We sought to develop an affordable, patient-facing electronic stethoscope of comparable quality to those existing that could seamlessly integrate with any telemedicine platform for real-time or asynchronous clinician review. Method(s): A rigorous design process guided by clinician and patient input generated nearly 100 concepts stratified through a pugh decision matrix in reference to an existing product, the Eko Core, to decide on the most suitable design - the AusculBand. With the form factor of a wrist-band, the AusculBand encases a custom bell with a high fidelity microphone and unique circuitry to sit comfortably in the palm of a user's hand to facilitate self-auscultation over the chest wall for real-time clinician review via telemedicine. Recognizing cardiac sounds to fall between 20 Hz and 2000 Hz, frequency response testing was conducted to determine the cut-off frequency of the AusculBand. With knowledge of an industry standard signal-to-noise ratio of 10.31 dB, a simple comparative study was devised between our novel AusculBand and the commercial Eko Core. With each device, a single-user in replicative fashion collected cardiac signals from the chest wall and background noise from the bicep to generate signal-to-noise ratio readouts and compare overall sound quality. Result(s): In response to frequency testing, the AusculBand was found to attenuate frequencies higher than 1997 Hz when testing a signal that swept through a range of 0 to 3,000 Hz at a constant amplitude. This result was within 0.2% of the 2000 Hz upper-limit of cardiac sounds and surpassing our design input goal of <= 1%. Signal-to-noise ratio analysis revealed 27.29 dB for the AusculBand and 24.02 dB for the Eko Core each exceeding the industry standard of 10.31 dB. Head-to-head comparison revealed the AusculBand achieved nearly double the loudness of the Eko Core. The projected price of the AusculBand is $80. The Eko Core is currently marketed at $350. Conclusion(s): The AusculBand is a cost-effective, patient-facing electronic stethoscope that surpasses industry standards in signal-to-noise ratio and is readily adaptable to popular telemedicine platforms. Additional modification is underway to add a single-lead electrocardiogram to bolster the device as an all-in-one, affordable and accessible telemedicine tool for cardiac analysis.Copyright © 2022

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

SARS-COV-2-INDUCED COAGULOPATHY DEMONSTRATING HEMORRHAGIC CARDIAC TAMPONADE: A TIGHT SQUEEZE

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: There is a growing volume of evidence of extrapulmonary manifestations of Coronavirus disease 2019 (COVID-19), particularly within the cardiovascular and hematological systems. In this case, we describe a unique manifestation of a COVID-19 presenting with a hemorrhagic pericardial effusion and cardiac tamponade physiology with a supratherapeutic international normalized ratio (INR). CASE PRESENTATION: A 68-year-old male with coronary artery disease and atrial fibrillation on warfarin presented to the emergency department with acutely worsening shortness of breath. Upon arrival, he was hypotensive, tachypneic, and hypoxic. Physical exam findings included jugular venous distention and muffled heart sounds. A transthoracic echocardiogram demonstrated a large concentric pericardial effusion with tamponade physiology (Figure 1). Pertinent initial laboratory values included an elevated INR of 6.1, a prolonged prothrombin time of 61.2 seconds, and an elevated D-dimer level of 5.34 mg/L (Table 1). The prolonged INR was reversed with prothrombin complex concentrate (PCC). Emergent pericardiocentesis yielded 1.7L of dark-bloody appearing fluid. Pericardial fluid analysis (Table 1) demonstrated over 2.4 million red blood cells and 3,650 total nucleated cells with 94% lymphocytes. Cultures and cytology were unrevealing. Given the profound lymphocytic component, a COVID-19 nasal swab was obtained and resulted positive. Prior to contracting COVID-19, the patient's weekly INR levels were consistently at goal. DISCUSSION: The global pandemic of the COVID-19 continues to identify extrapulmonary manifestations of the disease. A rising number of publications have implicated COVID-19 with causing myocarditis, pericardial effusions, and hemorrhagic cardiac tamponade(1). Hemorrhagic cardiac effusions are typically seen with malignancy, tuberculosis, trauma, recent cardiac procedures, post-myocardial infarction, and are also seen in Coxsackie viral infections. Multiple studies implicate COVID-19 interactions with oral-vitamin K antagonists as the cause of unpredictable INR's which can lead to spontaneous bleeding2. There are fewer than 10 reported instances of hemorrhagic pericardial effusions with tamponade physiology in COVID-19 patients;however, none of the other cases presented with a super-therapeutic INR. We are also the first to demonstrate a primary lymphocytic component of the pericardial fluid suggesting viral etiology. Profound coagulopathies in COVID-19 result in an increased mortality(3). CONCLUSIONS: We propose that based on the increase in publications of case-reports describing COVID-19 viral infections and hemorrhagic pericardial effusions, that SARS-CoV-2 should be added to the list of known viral etiologies. Further, COVID-19 patients who are systemic anticoagulation with vitamin K antagonists should be monitored closely for abrupt changes in their INR. Reference #1: 1. Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID-19. Nature Medicine. 2020;26(7):1017-1032. Reference #2: 2. Camilleri E, Van Rein N, Van Der Meer FJM, Nierman MC, Lijfering WM, Cannegieter SC. Stability of vitamin K antagonist anticoagulation after COVID-19 diagnosis. Research and Practice in Thrombosis and Haemostasis. 2021;5(7) Reference #3: 3. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis. 2020;18(4):844-847. DISCLOSURES: No relevant relationships by Gregory Hicks No relevant relationships by Daniel Kissau No relevant relationships by Andrew Labelle No relevant relationships by Scott Mayer No relevant relationships by Dmitriy Scherbak

PERICARDITIS EVOLVING INTO CARDIAC TAMPONADE IN A 76-YEAR-OLD PATIENT WITH COVID-19

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: Cardiac tamponade is a medical emergency that requires rapid diagnosis and intervention to prevent hemodynamic collapse. Although COVID-19 typically manifests with pulmonary symptoms, cardiac involvement is becoming better studied through increasingly frequently reported cases [1]. We present a case of COVID-19 cardiac involvement presenting as a rapidly progressive pericardial effusion turning into tamponade. This highlights the importance of a high index of suspicion for patients who develop sudden and atypical respiratory compromise with hypotension in the setting of COVID-19 infection. CASE PRESENTATION: A 76-year-old male with a history of ESRD presented with fatigue after missing hemodialysis. Laboratory investigations revealed a mild troponin elevation and positive SARS-CoV-2 PCR. Initial TTE demonstrated an EF of 60-65% with a small pericardial effusion and thickened calcified pericardium. After a few days, the patient was noted to be encephalopathic and hypotensive. Labs revealed leukocytosis, lactic acidosis as well as an elevated troponin and D-dimer. Chest CTA was significant for a large pericardial effusion with reduced size of the right ventricle, concerning for cardiac tamponade. Repeat TTE had a moderate pericardial effusion and right atrial collapse, consistent with tamponade. Given significantly elevated INR in the setting of anticoagulation, pericardiocentesis was deferred while the patient was transfused FFP. The patient subsequently suffered PEA arrest and expired despite attempted hemodynamic stabilization. DISCUSSION: Cardiac tamponade is a result of accumulating pericardial fluid culminating in decreased cardiac output and shock. Clinicians should be prompted by characteristic findings, including Beck’s triad (JVD, hypotension, and muffled heart sounds) and Kussmaul’s sign of paradoxically elevated JVP with inspiration [2]. However, the diagnosis of tamponade based solely on clinical finding is difficult and may lead to unnecessary intervention [3]. Ultimately, a diagnosis of tamponade requires both hemodynamic instability and pericardial effusion. Echocardiography, including TTE and POCUS, plays a central role in the identification of cardiac tamponade. While it is essential to note the presence of a pericardial effusion, it is important to be familiar with core echocardiographic signs of tamponade: systolic RA collapse (earliest sign), diastolic RV collapse, IVC with minimal respiratory variation, and exaggerated respiratory cycle changes in MV and TV in-flow velocities (a surrogate for pulsus paradoxus) [3]. CONCLUSIONS: Despite the classic association between COVID-19 and pulmonary manifestation, pericardial involvement has been noted in 20% of COVID-19 patients. It is therefore imperative to maintain a high index of suspicion and familiarity of characteristic echocardiogram findings of tamponade to prompt intervention and curtail cardiac hemodynamic collapse. Reference #1: Lala A, Johnson KW, Januzzi JL, et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J Am Coll Cardiol. 2020;76(5):533-546. doi:10.1016/j.jacc.2020.06.007 Reference #2: Stashko E, Meer JM. Cardiac Tamponade. [Updated 2021 Dec 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/ Reference #3: Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j.ajem.2018.11.004 DISCLOSURES: No relevant relationships by Christopher Allahverdian No relevant relationships by John Javien No relevant relationships by Vishal Patel No relevant relationships by Sarah Youkhana

DESIGNING A COST-EFFECTIVE, PATIENT-FACING DIGITAL STETHOSCOPE FOR TELEMEDICAL CARDIAC AUSCULTATION

Introduction: The COVID-19 pandemic catalyzed growth of virtual medicine, challenging providers to adapt their standard protocols for telehealth. During this time, cardiologists were unable to gather numerical/graphical heart data to guide therapy. Many examination technologies exist in-person to obtain this data, but they are not engineered for patient use during virtual visits. Objective: The team sought to develop an inexpensive diagnostic point-of-care device designed to work with telehealth applications and provide patients with the ability to transmit data on cardiovascular function to physicians in real time. Methods: The AusculBand used clinician and patient input for final design format. The AusculBand is shaped like a wristband and encapsulates a custom bell, microphone, and novel circuitry to facilitate self-auscultation for live transmission to a virtual physician. Frequency response testing was designed to verify the AusculBand’s captured cardiac sound frequency range. A comparative study was designed to test audio quality against and the Eko Duo’s, a leading competitor. Repeated cardiac auscultation signals at different points and background noise using both devices were obtained to quantify signal-to-noise ratio (SNR) on one user. Results: During frequency response analysis, the AusculBand captured frequencies up to 1997Hz in response to a signal that swept through a range of 0-3kHz. These results were within 0.2% of the 2kHz upper-limit of the cardiac range. SNR testing showed 27.29dB for the AusculBand and 24.02dB for the Eko Duo. The AusculBand is nearly twice as loud as the Eko Duo, and maintains a projected price of $80 (Eko Duo $320). Conclusions: The AusculBand is an inexpensive, patient-oriented digital stethoscope that beats industry standards in SNR and is compatible with existing telehealth platforms. Future modifications will add a single-lead ECG to promote the device as an all-in-one telemedicine tool for virtual cardiac analysis. [Formula presented] [Formula presented]

Effective features extraction by analyzing heart sound for identifying cardiovascular diseases related to COVID-19: A diagnostic model.

Incidence and exacerbation of some of the cardiovascular diseases in the presence of the coronavirus will lead to an increase in the mortality rate among patients. Therefore, early diagnosis of such diseases is critical, especially during the COVID-19 pandemic (mild COVID-19 infection). Thus, for diagnosing the heart diseases related to the COVID-19, an automatic, non-invasive, and inexpensive method based on the heart sound processing approach is proposed. In the present study, a set of features related to the nature of heart signals is defined and extracted. The investigated features included morphological and statistical features in the heart sound frequencies. By extracting and selecting a set of effective features related to the mentioned diseases, and avoiding to use different segmentation and filtering techniques, dependence on a limited dataset and specific sampling procedures has been eliminated. Different classifiers with various kernels are applied for diagnosis in data unbalanced and balanced conditions. The results showed 93.15% accuracy and 93.72% F1-score using 60 effective features in data balanced conditions. The identification system using the extracted features from Azad dataset is able to achieve the desired results in a generalized dataset. In this way, in the shortest possible sampling time, the present system provided an effective and generalizable method and a practical model for diagnosing important cardiovascular diseases in the presence of coronavirus in the COVID-19 pandemic.

TRACKING DOWN AUTOANTIBODIES

Background/Aims Vaccine-associated autoimmunity is not infrequent, pertaining to either the cross-reaction between antigens or the action of adjuvant. This issue is more inexplicable to the COVID-19 vaccine, because of nucleic acid formulation and the hastened development process inflicted by the urgent pandemic condition. Here we are presenting a young patient who developed a significant abnormal autoimmune profile immediately post covid vaccination. Methods A 31-year-old IT engineer was referred to Rheumatology with postvaccine arthralgia. He had a history of recent aortic root aneurysm repair after having chest pain on exertion. Echocardiography showed dilated aortic root with significant aortic regurgitation, CT aortogram confirmed spiral type A dissection. He underwent an emergency cardiothoracic surgery in October 2020, followed by an uneventful recovery. He received the first dose of Pfizer COVID-19 vaccine on 2nd February, the very next day he developed painful ankles, knees, left hip, and right shoulder. Blood tests showed elevated CRP of 45, ESR 34, rheumatoid factor positive at 92, anti-CCP >340, ANA 13, ds-DNA 202, U1RNP positive, anti-SM antibody positive, Ro and La antibodies positive, antiJo1 antibody positive, with normal complements. He denied any swelling of the joints. No history of hair loss, photosensitive skin rashes, Raynaud's, sicca symptoms, oro-genital ulceration, or cracking of the skin. There were no constitutional symptoms, chest pain, or bowel issues. He was previously labeled as asthmatic, which is stable after surgery. He doesn't smoke or drinks alcohol. There was no family history of autoimmune conditions. On examination, he has tenderness across both hands and wrists with palmar erythema but no synovitis. He has painful right shoulder abduction with left hip pain on flexion and extension. Cardiovascular and GI examination was unremarkable apart from sternotomy scar and metallic valvular heart sounds. His dipstick urinalysis was negative for blood and protein. In recent x-rays hands and feet were normal. We agreed on a trial a tapering course of prednisolone started with 20mg daily. Three weeks later in follow-up, he reported partial response to steroids. His inflammatory markers were coming down. We have started azathioprine as a steroid-sparing agent. Results This gentleman with negative autoimmune screening prior to cardiothoracic surgery expressed florid newly detected autoantibodies straightaway after the COVID-19 vaccine. This is suggestive of undifferentiated connective tissue disease with the likelihood of overlap syndrome between rheumatoid arthritis and SLE. Conclusion COVID-19 vaccination showed a beacon of light to end the pandemic by achieving herd immunity. There is an excusable socioeconomic rush towards mass vaccination without long-term safety analysis, however, it is also crucial that any vaccine licensing process should entail meticulous scrutiny of the human proteome against vaccine peptide sequences. This will minimize the risks of acute autoimmune reactions to inoculation and future chronic autoimmune pathology.

A CASE OF IDIOPATHIC HEMORRHAGIC PERICARDIAL EFFUSION: NO CLUES LEFT BEHIND

Background: Hemorrhagic pericardial effusion (HPE) is an infrequently encountered entity. We present here a challenging case of HPE. Case: A 67-year-old woman with history of hypothyroidism presented with dyspnea, chest discomfort, chills since 2 weeks. She had received mRNA-1273 vaccine 7 days prior to presentation. Vitals were notable for a heart rate of 136/min, otherwise she was hemodynamically stable. Physical exam was notable for muffled heart sounds. Decision-making: Labs showed a hemoglobin of 9.6 g/dL, C reactive protien(CRP) of 93.80 mg/L, normal thyroid profile and troponin, and a negative COVID-19 PCR. ECG was suggestive of sinus tachycardia. An Echocardiogram showed ejection fraction of 55-60% and large pericardial effusion with tamponade physiology. Emergent pericardiocentesis was done, removing 940 mL of sanguineous fluid. Pericardial fluid showed predominantly red blood cells;cytology was negative for malignant cells. Infectious workup for fungal, viral, tuberculosis and bacterial infections, and antibody testing as a part of rheumatologic workup was negative. A CT of the chest, abdomen and pelvis did not show any evidence of malignancy. She remained hemodynamically stable and was discharged on colchicine and ibuprofen. The patient did well on follow up at one month. Conclusion: Despite extensive workup, underlying etiology of HPE was not identified. As the symptoms preceded vaccination, the likelihood of vaccine-induced pericarditis and HPE was deemed low. [Formula presented]

Purulent pericarditis can be near fatal

A previously healthy 27 years-old male presented with 2 weeks of substernal chest pain, progressive dyspnea, palpitations, dizziness, and(&) fever. On exam, he had tachypnea & tachycardia, was hypotensive with an elevated JVP & muffled heart sounds. Labs showed elevated WBC, CRP, lactate & high sensitive troponin. Negative for COVID-19, flu. EKG showed sinus tachycardia. CT showed large pericardial effusion with gas in the pericardial space. Echo (Figure 1) revealed large pericardial effusion with tamponade. Emergent pericardiocentesis was performed draining a liter of straw-colored thick fluid (fluid: serum LDH >3) (Figure 2). Cultures grew Strep. Anginosus & Propionibacterium acnes. Extensive infectious & immunological workup returned negative. He had initially improved on broad-spectrum antibiotics however declined clinically on day 5. Repeat CT (Figures 3 & 4) showed recurrent pericardial effusion & mediastinal abscess with trace extravasation of contrast from the esophagus to posterior mediastinum. We present a case of esophageal perforation leading to Pyopneumopericardium. Stephenson et al. reported a case series of 13 patients with esophagopericardial fistulas & pyopneumopericardium with a 100% mortality rate. Another case series showed survival rates of only 17% in 60 patients with pyopneumopericardium secondary to esophageal perforation. Erosion of esophageal ulcers, ingestion of foreign body, iatrogenic, trauma, malignancy, localized inflammation can lead to esophageal perforation. Streptococcus pneumoniae & Staphylococcus aureus are common pathogens involved. Constrictive pericarditis is a possible complication in up to 20 to 30%. Our patient underwent pericardial window & surgical debridement followed by EGD-guided gastro-jejunal tube placement. He did well after 4 weeks of IV antibiotics. Our case demonstrates that early recognition & intervention can favorably alter the course of this potentially fatal cardiac condition.

COVID-19 masquerading as myositis and myopericarditis

Case report-IntroductionCoronavirus (SARS-COV-19) typically targets the respiratory tract;however extra-respiratory manifestations such as myositis and myopericarditis may be the only presenting feature.We present a patient with myopericarditis who developed sudden onset muscle weakness. CT thorax showed typical appearance of COVID-19 with an absence of respiratory symptoms. MRI of both thighs revealed diffuse symmetrical myositis. Her clinical and paraclinical abnormalities improved with the aid of steroids. We present our approach to the case and highlight that clinicians should consider myositis as another COVID-19 manifestation when reviewing the differentials.Case report-Case descriptionA 50-year-old female, non-smoker, presented with few days history of central chest pain radiating to her back. This was exacerbated by lying down and inspiration. Associated with mild shortness of breath on exertion. She denied upper respiratory tract symptoms.Her past medical history included hypertension and myopericarditis in 2012 and 2013 requiring pericardiocentesis. In 2017 she presented with post-streptococcal erythema nodosum and reactive arthritis in left ankle.On auscultation her heart sounds were normal, and chest was clear. Initial investigations revealed a mild lymphopenia 0.63, a C-reactive protein of 11mg/L, and a raised troponin 77 and 103 on repeat. D-dimer, Chest X-ray were normal. ECHO showed trivial anterior pericardial effusion, good biventricular function. Treatment included colchicine 500 micrograms four times a day and Ibuprofen 400 mg three times a day.On her second day of admission she developed hypotensive episodes BP 75/49 mm/Hg and mild pyrexia of 37.5 degrees. Her chest pain continued. Electrocardiogram was normal, repeat echocardiogram showed stable 1.40 cm pericardial effusion. CT thorax revealed no dissection or features suggesting pulmonary sarcoidosis but ground-glass opacity changes in keeping with COVID-19. Her COVID-19 swab test came back positive.On the 4th day of admission, she complained of sudden onset of severe pain affecting her thighs, shoulders, and arms, with marked proximal lower limbs and truncal weakness. Because of this, she struggled to mobilise. There was a rapid rise in her creatine kinase from 6.423U/L (day 5) to 32.230 U/L (day 7). ALT increased to 136. MRI showed diffuse myositis with symmetrical appearances involving the anterior, medial, and posterior muscle compartments of both thighs.In view of her previous and current presentation, autoimmune screen and extended myositis immunoblot were sent and were negative. Interestingly, her clinical and paraclinical abnormalities improved dramatically after few days with no steroids initially.Case report-DiscussionThe identification of extra-pulmonary manifestations neurological, cardiac, and muscular have recently increased as the number of COVID-19 cases grow.This case highlights cardiac and skeletal muscle involvement could perhaps represent early or only manifestation of COVID-19.Cardiac involvement in COVID-19 commonly manifests as acute cardiac injury (8-12%), arrhythmia (8.9-16.7%) and myocarditis. In our case the cardiac MRI demonstrated evidence of myocarditis in the basal inferoseptum and apex.Myalgia and muscle weakness are among the symptoms described by patients affected by COVID-19. Some studies report the prevalence of myalgia to be between 11%-50%. The onset of symptoms and the fact that her symptoms improved rapidly led us to consider a viral myositis as the underlying cause, the viral component being COVID-19. We also considered other potential causes. There are reported cases of colchicine myopathy however this is more common in patients with renal impairment, which was absent in this case.On further examination she did not have other clinical signs or symptoms of connective tissue disease or extra muscular manifestation of autoimmune myositis.Her abnormal ALT may be derived from damaged muscle, and therefore in this context is not necessarily a specific indicator of liver disease. Interestingly abnormal live function tests have been attributed in 16-53% of COVID-19 cases.Little is known about the multiple biologic characteristics of COVID-19 and there are no established clinic serological criteria for COVID-19 related myositis nor useful values/cut offs to exclude cardiac involvement in myositis, further research is therefore warranted.In conclusion, clinicians should be aware of the rare manifestation of COVID-19 and consider this in the differentials. Of course, it is important in the first instant to rule out any serious underlying disease or overlap disorder before attributing symptoms to COVID-19.Case report-Key learning points Myositis is a rare manifestation of COVID-19 that clinicians should be aware of.Detailed medical history, examination and investigations identifies the most likely underlying cause.In the right clinical context, COVID-19-19 testing should be included in baseline tests of patients presenting with myositis.