Rare case of infective aortitis with aortic rupture and cardiac tamponade in a young child.

Aortitis and aortic dissection are very rare in children. The clinical presentation of aortitis varies across a spectrum, ranging from incidental findings to fatal aortic dissection and rupture. A high index of suspicion is needed to establish an accurate and timely diagnosis. Here, we present an unfortunate case of fatal infective aortitis with aortic rupture and cardiac tamponade in a healthy toddler. Postmortem report implicated Kingella kingae as the causative organism of aortic pseudoaneurysm and rupture, leading to the instantaneous death of the child.

Contribution of Cardiovascular Disease to Adverse Hospital Outcomes in Covid-19 Hospitalizations: Results from National Inpatient Sample

Background It is a well-established fact that cardiovascular disease (CVD) adversely affects COVID-19 outcomes. However, the extend of the burden posed by CVD on hospitalized COVID-19 patients in the United States is unknown. In this study, using a national database, we estimated the effects CVD on COVID-19 hospitalizations in the United States. Methods This study is a retrospective analysis of National Inpatient Sample data, collected during 2020. Patients >=18 years of age, admitted with primary diagnosis of COVID-19 were included in the analysis. CVD was defined as presence of coronary artery disease, myocardial infarction, heart failure, sudden cardiac arrest, conduction disorders, cardiac dysrhythmias, cardiomyopathy, pulmonary heart disease, venous thromboembolic disorders, pericardial diseases, heart valve disorders, or peripheral arterial disease. The primary outcomes of the study were in-hospital mortality rate, prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Multivariable logistic regression analysis was done to examine the association between presence of CVD and primary outcomes. Results During 2020 there were 1,050,040 COVID-19 hospitalizations in the United Sates. Of these 454650 (43.3%) had CVD. COVID-19 patients with CAD were older, males, and had higher comorbidity burden. The odds of in-hospital mortality (OR, 3.40;95% CI: 3.26-3.55), prolonged hospital length (OR, 1.71;95% CI: 1.67-1.76) and mechanical ventilation use (OR, 3.40;95% CI: 3.26-3.55), and disposition other than home (OR, 2.11;95% CI: 2.06-2.16) were significantly higher for COVID-19 hospitalizations with CAD. Mean hospitalization costs were also significantly higher among COVID-19 patients with CAD ($24,023 versus $15,320, P<0.001). The total cost of all COVID-19 hospitalizations during 2020 was $19.9 billion - $10.9 billion for those with CAD and $9.0 billion for those without CVD. Conclusion Cardiovascular disease was present in a substantial proportion of COVID-19 patients hospitalized in the United States and contributed to considerable adverse hospital outcomes and significantly higher hospitalization cost.Copyright © 2023 American College of Cardiology Foundation

Pediatric Pericarditis: Update.

PURPOSE OF REVIEW: While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis. RECENT FINDINGS: We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis. CASE VIGNETTE: A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

Rare atypical presentation of a polymicrobial gastropericardial fistula.

We present the unique case of a gastropericardial fistula with a rare, delayed presentation in a man in his 70s. Relevant surgeries include Watchman Left Atrial Appendage Closure device placement 1 year prior to arrival and gastric bypass surgery 20 years prior to arrival. The patient presented to the emergency department with weakness, diarrhoea and left knee pain. He was admitted for cellulitis of the left lower extremity, prosthetic septic arthritis of the left knee and group G streptococcus bacteraemia. His hospital course was complicated by acute chest pain and dyspnoea. Imaging revealed pneumopericardium. Oesophagogastroduodenoscopy visualisation confirmed the diagnosis of gastropericardial fistula. The patient could not be transferred to a tertiary centre for definitive management because of the effect of the COVID-19 pandemic on tertiary hospital volumes. After pericardial drainage and administration of antimicrobials without improvement, the patient was discharged to hospice care at his request and died 1 day after discharge.

Cardiac complications from multisystem inflammatory syndrome associated with prior COVID-19 infection.

Multisystem inflammatory syndrome in adults (MIS-A) is a systemic inflammatory condition that presents roughly 4-6 weeks after initial COVID-19 infection. Patients typically present with persistent fevers, widespread rash, abdominal pain, vomiting and diarrhoea, and new-onset neurological symptoms. Cardiac dysfunction is a prominent feature of COVID-19 sequelae due to the abundance of ACE2 receptors on cardiac tissue. Delayed diagnosis due to the novelty of MIS-A can lead to cardiac complications like heart failure and shock, which could result in chronic cardiac disease. Avoidance of complications and chronic illness is possible with prompt corticosteroid therapy. Despite patient recovery to baseline level of function, surveillance of cardiac function to screen for chronic cardiac disease in the follow-up period is recommended. We present a case of MIS-A in a young man, compare his presentation with other similar cases and discuss implications of delayed diagnosis.

Severe myopericarditis following the third dose of an mRNA COVID-19 vaccine: utility of a multimodal treatment approach.

We report a rare case of severe myopericarditis in a healthy man in his 20s after the third dose of an mRNA COVID-19 vaccine. His symptoms and troponinemia resolved with a beta-blocker in addition to standard anti-inflammatory therapy, highlighting the utility of multimodal therapy.

COVID-19 presenting as acute pericarditis.

COVID 19, caused by SARS-CoV-2, is a highly infectious disease, mainly affects the respiratory system. In this article, we have presented a case of COVID-19, who presented solely with pericarditis without myocarditis, without any respiratory symptoms. The diagnosis was made based on clinical, electrocardiographic, radiological and biological findings. He was treated successfully with aspirin and colchicine. Our case highlights an atypical presentation of COVID-19, which should be kept in mind in the present pandemic and to diagnose and isolate early to limit the spread of infection.

Reconsideration of the ECG in pericarditis; have we been led astray all these years?

Recently, new criteria for the diagnosis of pericarditis have been published. This paper has been thought to point out the limits in the new criteria specificity as well in the application of the new criteria for the diagnosis of pericarditis as recently demonstrated by studies based on cardiac magnetic resonance imaging. We report the case of A 18y old male with no significant past medical history who presented with complaints of chest pain typical for pericarditis, initially labeled as pericarditis; the patient was evaluated by electrocardiography, trans-thoracic echocardiography and cardiac magnetic resonance imaging; the condition, based on electrocardiogram and trans-thoracic echocardiography findings, was labeled as pericarditis in keeping with current diagnostic criteria. Cardiac magnetic resonance imaging demonstrated myocardial edema with no T2-defined pericardial inflammation on TIR/T2 imaging; late gadolinium enhancement imaging demonstrated multiple irregular, punctate, epicardial zones. The constellation of findings was consistent with acute myocarditis without pericardial involvement. In conclusion, limits in specificity of the newly published criteria for diagnosis of pericarditis, which add to the already demonstrated limits in sensitivity, subsist. Cardiac magnetic resonance imaging plays a unique role in the initial assessment of pericarditis; this is particularly important in the Covid-19 era in light of the increasing incidence of myocarditis and pericarditis; also, the case suggests that the combination of information between advanced echocardiography and cardiac magnetic resonance imaging may have an important diagnostic role in this setting. Additionally, we suggest that despite recent enthusiasm for colchicine, its role may be best defined in those with myocarditis, not pericarditis.

Cardiac tamponade and massive pleural effusion in a young COVID-19-positive adult.

COVID-19 has a broad spectrum of cardiac manifestations, and cardiac tamponade leading to cardiogenic shock is a rare presentation. A 30-year-old man with a history of COVID-19-positive, reverse transcription polymerase chain reaction (RT-PCR) done 1 week ago and who was home-quarantined, came to the emergency department with palpitations, breathlessness and orthopnoea. His ECG showed sinus tachycardia with low-voltage complexes, chest X-ray showed cardiomegaly and left pleural effusion and two-dimensional echocardiography showed large pericardial effusion with features suggestive of cardiac tamponade. He was taken up for emergency pericardiocentesis which showed haemorrhagic pericardial fluid. Intercostal drainage insertion was done for left-sided large pleural effusion. After ruling out all the other causes for haemorrhagic pericardial effusion, the patient was started on colchicine, steroids, ibuprofen and antibiotics to which he responded. Both pericardial and pleural effusions resolved completely on follow-up.

COVID-19-associated myocarditis presenting as new-onset heart failure and atrial fibrillation.

A 58-year-old man presented to the emergency department with recent-onset palpitations and progressive exertional dyspnoea. ECG demonstrated new-onset atrial fibrillation. Transthoracic echocardiogram showed global impairment in left ventricular systolic function with left ventricular ejection fraction of 20%. Cardiac MRI (CMRI) demonstrated generalised severe myocarditis. A SARS-CoV-2 PCR was positive for SARS-CoV-2 RNA. As such, we diagnosed our patient with COVID-19-associated myocarditis based on CMRI appearances and positive SARS-CoV-2 swab. This case highlights that COVID-19-associated myocarditis can present as new atrial fibrillation and heart failure without the classic COVID-19-associated symptoms.

Subacute effusive-constrictive pericarditis in a patient with COVID-19.

We report the case of a previously healthy young woman, who developed a severe form of COVID-19 with massive pneumonia and acute pericarditis in whom constrictive physiology developed rapidly. To our knowledge, this represents the second reported case of SARS-CoV-2 constrictive pericarditis, a rare, but severe cardiac complication.

Pericardial Diseases in COVID19: a Contemporary Review.

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID19) involves the heart, including pericardium. This article reviews the possible pathophysiological mechanisms in pericardial involvement in COVID19 and pericardial manifestations of COVID19. It also summarizes the patients with pericarditis secondary to COVID19 and outlines the contemporary treatment strategies in this patient population. RECENT FINDINGS: A high degree of suspicion is required to identify the pericardial involvement in COVID19 patients. It is proposed that an underlying hyperinflammatory reaction in COVID19 leads to pericardial inflammation. Acute pericarditis with or without myocardial involvement is diagnosed on clinical presentation, serum inflammatory markers, electrocardiogram, and echocardiogram. Multimodality imaging may also have an additional diagnostic value. Patients are usually managed medically, but some patients develop a life-threatening pericardial tamponade necessitating pericardial drainage. Pericardial involvement is an important clinical manifestation of COVID19 requiring a proper workup. Timely diagnosis and a specific management plan based on the presentation and concomitant organ involvement usually lead to a complete recovery.

Coronavirus disease 2019 (COVID-19)-associated constrictive pericarditis.

This report documents a rare case of COVID-19-associated constrictive pericarditis (CP) in the setting of a recent COVID-19 infection. A 55-year-old man with a history of hypertension and gout presented with acute hypoxic respiratory failure and was diagnosed with COVID-19 pneumonia with progression to acute respiratory distress syndrome. His hospital course was complicated by a large pericardial effusion; an emergent bedside transthoracic echocardiography was concerning for cardiac tamponade, so pericardiocentesis was performed. A workup with cardiac magnetic resonance imaging showed changes consistent with a diagnosis of CP. Viral and idiopathic aetiologies are the most common cause of CP in the developed world, with COVID-19 now a proposed predisposing viral illness. The virus induces systemic inflammation and pericardial changes that can lead to CP physiology. Imaging modalities including echocardiogram and cardiac magnetic resonance play an integral role in confirming the diagnosis.

Challenges in Managing Pericardial Disease Related to Post Viral Syndrome After COVID-19 Infection.

Although primarily a respiratory illness, coronavirus disease 2019 (COVID-19) has been associated with cardiac involvement with reported cases of myocardial ischemia, arrhythmia, myocarditis, pericarditis, and pericardial effusion leading to cardiac tamponade. Most cases of pericardial disease in this setting have been during the acute infection. Here, we present a patient who developed pericarditis leading to cardiac tamponade after the resolution of the acute COVID-19 infection. Her course of illness was further complicated by poor response to initial medical therapy with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine which could possibly be related to early exposure to steroids. It is often difficult to establish an underlying etiology for acute pericarditis. Similarly, in our case, although there is no definitive test to prove the causal relationship, this effusion is highly suspicious of being secondary to post viral sequelae after COVID-19 infection when considering the clinical course. It is important to consider pericardial disease as a late complication of COVID-19 even after apparent resolution of the acute infection and be mindful of the therapeutic challenges that we might face while managing such patients.

Hypereosinophilic syndrome with multiorgan involvement: an interdisciplinary work-up.

A previously healthy 40-year-old man was referred to our emergency department with pruritic skin lesions and dyspnoea. Laboratory investigation revealed hypereosinophilia. Further diagnostic work-up confirmed the diagnosis of idiopathic hypereosinophilic syndrome (iHES), a rare myeloproliferative disease with a heterogeneous clinical presentation. We describe a unique case with cardiac, pulmonary, hepatic and cutaneous involvement at time of presentation. This case accentuates the importance of an extensive multidisciplinary diagnostic work-up, since iHES is a condition with potential rapid progressive multiorgan failure which requires prompt analysis and treatment. In addition, this case emphasises the importance of being aware of tunnel vision, especially during the COVID-19 pandemic, which might give rise to an increased risk of missing rare diagnoses. Our patient was treated with prednisolone, after which both his clinical condition and eosinophil concentrations markedly improved.

Myocarditis in SARS-CoV-2 negative patients with suspected preceding infection.

SARS-CoV-2 is primarily a respiratory disease; however, there have been multiple reports of associated myocarditis. In our 463 bedded, district general hospital, we noted an influx of young patients with myocarditis shortly after the peak of the outbreak. We report two cases presenting with myocarditis, both of whom tested negative for the virus despite clinical and biochemical evidence of recent infection. Diagnosis was made based on positive transthoracic echocardiogram (TTE) findings and a raised troponin, not in the context of suspected acute coronary syndrome. We recommend that patients with negative coronavirus tests should still be considered at risk of potential sequelae from the disease. There should be a low threshold for performing basic cardiac investigations: ECG, troponin and TTE as well as seeking a cardiology opinion. Colchicine is a recognised treatment for viral pericarditis and should be considered as adjunctive treatment; however, further research is required specific to SARS-CoV-2.

Rare complication after pericardial window: symptomatic diaphragmatic hernia containing bowel and liver.

A 37-year-old woman presented to her local district general hospital with a cough, pleuritic chest pain and intermittent cyanosis. Eight months prior, she underwent a successful pericardial window for recurrent, symptomatic pericardial effusions. On presentation she was hypoxic but haemodynamically stable. Her chest radiograph raised the suspicion of a diaphragmatic hernia, confirmed by CT imaging. This identified herniation through the diaphragm of the transverse colon and left lobe of the liver resulting in cardiac compression and right ventricular dysfunction. She continued to deteriorate and required emergency intubation to allow safe transfer to a tertiary upper gastrointestinal unit. She underwent a laparotomy and repair of the diaphragmatic hernia with an uneventful inpatient recovery. In the literature, diaphragmatic liver herniation is a recognised complication secondary to trauma or congenital defects, however, to our knowledge, there are currently no cases described following pericardial windowing.

Fulminant myocarditis as an early presentation of SARS-CoV-2.

Myocarditis is well known to be caused by viral infections such as Coxsackie virus group B, human herpes virus 6 and parvovirus B19. However, during the current emerging outbreak of SARS-CoV-2, there have been few case reports describing myocarditis as a possible presentation. In our case report we describe, early cardiac manifestations of SARS-CoV-2 in a UK District General Hospital. A 44-year-old Caucasian woman without any comorbidities presented with SARS-CoV-2 related fulminant myocarditis without initial respiratory symptoms. Patient underwent treatment with milrinone and methylprednisolone that showed reduction in myocardial inflammation and significantly improved myocardial contractility. This was then followed by a second phase of SARS-CoV-2 associated pneumonia and renal failure requiring ventilatory support and haemofiltration. Although, not described in the literature, we have found conjunctive use of milrinone and methylprednisolone effective in patient with SARS-CoV-2 fulminant myocarditis.

Acute pericarditis as a primary presentation of COVID-19.

The COVID-19 pandemic is a highly contagious viral illness which conventionally manifests primarily with respiratory symptoms. We report a case whose first manifestation of COVID-19 was pericarditis, in the absence of respiratory symptoms, without any serious complications. Cardiac involvement in various forms is possible in COVID-19. We present a case where pericarditis, in the absence of the classic COVID-19 signs or symptoms, is the only evident manifestation of the disease. This case highlights an atypical presentation of COVID-19 and the need for a high index of suspicion to allow early diagnosis and limit spread by isolation.