Presentation of Takotsubo Cardiomyopathy in a Patient with Coronavirus-19 Disease

Case Report: It is well documented that Coronavirus Disease 19 (COVID-19) patients who suffer cardiac injury have a higher mortality rate, however the exact mechanism of cardiac injury and potential complications are still unknown. Takotsubo Cardiomyopathy (TCM), which was first described in 1990 in Japan, is characterized by a transient systolic and diastolic left ventricular dysfunction with a range of wall motion abnormalities predominantly affecting women often following an emotional or physical trigger. Though TCM is seen less commonly as a cardiac complication of COVID-19, with increasing rates of cardiovascular events due to COVID-19, TCM should be taken into consideration as a potential diagnosis for a COVID-19 positive patient. Case Description: The case of a 75-year old female with a history significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease presented to the Emergency Department after a ground level fall and subsequent left hip pain. Upon primary survey, EKG showed persistent sinus tachycardia in the 130-150s, with intermittent borderline dynamic changes and a troponin that was mildly elevated at 0.10, and an initial false negative COVID-19 test. Preoperative echocardiogram showed normal left ventricle size, no regional wall abnormalities, and a left ventricular ejection fraction (LVEF) of 60-65%. In post-operative care, EKG illustrated dynamic changes in the form of ST elevation in the lateral precordial leads, as well as an increase in the cardiac troponins, from 0.07 to 3.51. A subsequent echocardiogram illustrated a drop in her ejection fraction from 60-65% to 30-35%, with evidence of left ventricular systolic dysfunction that was not noted on previous echocardiograms. Following the Mayo clinic diagnostic criteria, this patient met the diagnostic criteria for TCM, as evident by new electrocardiograph findings, non-obstructive cardiac catherization findings, echocardiogram findings illustrating transient left ventricular systolic dysfunction, modest elevations in cardiac troponins as well as the patient being a post-menopausal female. Subsequent echocardiogram on 2 week follow up showed a rebound in her ejection fraction to 50-55%. Discussion(s): Possible outcomes of TCM include cardiogenic shock, respiratory failure, and death. It is imperative that clinicians consider TCM as a possible diagnosis when treating COVID-19 patients that may be exhibiting cardiac complications. Frequent ECG monitoring and a vigilant differential should include TCM in patients presenting with COVID-19.

Cardiac MRI in patients with COVID-19 infection.

OBJECTIVE: COVID-19 infection is a systemic disease with various cardiovascular symptoms and complications. Cardiac MRI with late gadolinium enhancement is the modality of choice for the assessment of myocardial involvement. T1 and T2 mapping can increase diagnostic accuracy and improve further management. Our study aimed to evaluate the different aspects of myocardial damage in cases of COVID-19 infection using cardiac MRI. METHODS: This descriptive retrospective study included 86 cases, with a history of COVID-19 infection confirmed by positive RT-PCR, who met the inclusion criteria. Patients had progressive chest pain or dyspnoea with a suspected underlying cardiac cause, either by an abnormal electrocardiogram or elevated troponin levels. Cardiac MRI was performed with late contrast-enhanced (LGE) imaging, followed by T1 and T2 mapping. RESULTS: Twenty-four patients have elevated hsTnT with a median hsTnT value of 133 ng/L (IQR: 102 to 159 ng/L); normal value < 14 ng/L. Other sixty-two patients showed elevated hsTnI with a median hsTnI value of 1637 ng/L (IQR: 1340 to 2540 ng/L); normal value < 40 ng/L. CMR showed 52 patients with acute myocarditis, 23 with Takotsubo cardiomyopathy, and 11 with myocardial infarction. Invasive coronary angiography was performed only in selected patients. CONCLUSION: Different COVID-19-related cardiac injuries may cause similar clinical symptoms. Cardiac MRI is the modality of choice to differentiate between the different types of myocardial injury such as Takotsubo cardiomyopathy and infection-related cardiomyopathy or even acute coronary syndrome secondary to vasculitis or oxygen-demand mismatch. KEY POINTS: • It is essential to detect early COVID-related cardiac injury using different cardiac biomarkers and cardiac imaging, as it has a significant impact on patient management and outcome. • Cardiac MRI is the modality of choice to differentiate between the different aspects of COVID-related myocardial injury.

Acute Cardiovascular Complications of COVID-19: A Systematic Review.

Since the pandemic in 2019, coronavirus 2019 (COVID-19) has continued to be linked with a variety of organ systems and complications. While it is generally considered a respiratory disease, its link with the heart is widely discussed in the literature. This article focuses on the acute cardiovascular complications of COVID-19 and the possible predictors of these complications. Our study included 97 articles (58 case reports, eight case series, 23 retrospective cohort studies, five prospective cohort studies, and three cross-sectional studies). Several mechanisms have been proposed to explain COVID-19-induced cardiovascular complications, with cytokine-induced inflammation and direct cardiac damage noted as the significant focus. Patients with underlying cardiovascular complications such as hypertension and diabetes were noted to be at increased risk of acute cardiovascular complications, as well as an increased risk of severe disease and death. Also, acute myocardial infarction and arrhythmias were two of the most common acute cardiovascular complications noted in our review. Other acute cardiovascular complications are myocarditis, takotsubo syndrome, acute thromboembolic events, and pericardial complications. This article provides an updated review of acute cardiovascular complications of COVID-19, its pathogenesis, and risk stratification and emphasizes the need for high suspicion in patients with underlying cardiovascular risk factors.

Cardiovascular features and risk of mortality in COVID-19 hospitalized patients in Spain during 2020. A nationwide study from the Minimum Basic Data Set

Introduction: During the last two years scientific evidence has been gathered regarding the cardiovascular complications of Covid-19. Nevertheless nationwide studies are still required to better understand both the incidence of less frequent clinical findings, and the prognostic implications of cardiovascular COVID-19 complications. Purpose(s): The aim of this study was to estimate the incidence of cardiovascular diseases among COVID-19 hospitalized patients in Spain during 2020, as well as their association with mortality, besides other clinical and epidemiological factors. Method(s): We used the Minimum Basic Data Set from the Spanish Ministry of Health (RAE-CMBD) to analyze the data of all COVID-19 hospitalized patients in Spain during 2020. This national database includes concurrent diagnostics of all studied patients codified according to the Tenth International Classification of Diseases (ICD-10). Logistic regression analysis was performed to evaluate the influence of the different clinical and epidemiological variables in the evolution of COVID-19 hospitalized patients. Odds ratios were obtained for each variable adjusting by age and sex, and also adjusting by the rest of clinical factors. The software used for analysis was STATA v 16.1. Result(s): 75585 men (55.15%) and 61468 women (44.85%) were hospitalized due to COVID-19 during 2020 in Spain. The median age was 66 in men and 71 in women. Mortality was 14.92% in males, and 13.81% in females. 9.62% of patients were admitted to intensive care unit (ICU). Mortality in ICU was 29.13%. Heart Failure (7.8%), Atrial Fibrillation (7.7%), Pulmonary Embolism (3.46%), Supraventricular Arrythmias (1.18%), Cardiomyopathy (1.06%), Acute Coronary Syndrome (0.87%), Ischemic Stroke (0.33%), Myocarditis (0.12%) Pericarditis (0.06%), or Takotsubo Disease (0.05%), were relevant cardiovascular findings in COVID-19 hospitalized patients (Table 1). In the logistic regression multivariate analysis in COVID-19 patients we found epidemiological predictors of in-hospital mortality such as age (OR 2.38 for each decade), or male sex (OR 1.39). Among the clinical predictors of mortality we differentiated cardiovascular ones as Acute Coronary Syndrome (OR 1.51), Ischemic Stroke (OR 1.46), or Heart Failure (OR 1.43);and non cardiovascular ones such as admission to ICU (OR 3.12), Adult Respiratory Distress Syndrome (OR 2.74), need for Mecanical Ventilation (OR 2.52), Acute Kidney Failure (OR 2.07), Liver damage (OR 1.67), or Dementia (OR 1.66), (Table 2) Conclusion(s): Heart Failure, Pulmonary Embolism, Ischaemic Heart Disease, Atrial fibrillation, Ischemic Stroke, or Cardiomyopathy were among the main cardiovascular diseases associated to COVID-19. They increased in a different measure the risk of mortality in COVID-19, together with factors such as Mecanical ventilation, ICU admission, Acute kidney failure, Dementia, Liver damage, Adult Respiratory Distress Syndrome, older age, or male sex. (Table Presented).

Takostubo syndrome during the COVID-19 pandemic: A single center experience

Background: Takotsubo syndrome (TTS) is a major psychosomatic cardiovascular disease. It has been suggested that in the current pandemic of coronavirus disease 2019 (COVID-19), the psychological, mental and physical consequences of the restrictive measures taken to combat the pandemic, is likely to make individuals more vulnerable to TTS. Purpose(s): In our study, we investigated whether TTS incidence has increased during the COVID-19 era in a major tertiary hospital in Athens. Method(s): The study population included 316 consecutive patients admitted to the Coronary Care Unit (CCU) of our hospital throughout the 16 months (March 2020-June 2021) pandemic COVID-19 with the initial diagnosis of acute coronary syndrome (ACS). For comparison 342 patients with ACS admitted to CCU during the 16 months period preceding the COVID- 19 pandemic (November 2018-February 2020) were analyzed. All ACS patients underwent coronary angiography within 48 hours of admission. A prerequisite for admission to CCU of all ACS patients during the pandemic period was a negative reverse transcription-polymerase chain reaction test for COVID-19. Result(s): The vast majority (95%) of TTS patients were women and the mean age was 71.1+/-15.4 years. There was a significant increase in the incidence of TTS during the 16 months COVID-19 period (6.3%, i.e., 20 TSS among 316 ACS patients) compared with the corresponding incidence of TTS 16 months prior the pandemic (2.6%, i.e., 9 TTS among 342 ACS patients) [Figure 1]. The incidence rate ratio comparing the TTS cases of COVID-19 pandemic period to the pre-pandemic period was 2.22 (95% CI: 0.97-5.54, p=0.021). Conclusion(s): COVID-19 pandemic was associated with a significant increase in the incidence of TTSprobably due to the additional psychological burden imposed by the pandemic. (Figure Presented).

Dilated Cardiomyopathy: Unmasking Contributing Etiologies

Background: The role of genetic conditions in the development of cardiomyopathy is well established;however, recognition and referral for genetic testing remains underutilized. Systematic review of complex cases can increase general awareness in this area of practice. Here we describe the case of a patient with resolved severe stress induced cardiomyopathy (SIC), who was ultimately found to have heterozygous transthyretin-mediated amyloidosis (TTRA). Case: A 27-year-old man (family history positive for a brother status post heart transplant) presented with ataxia and cough due to legionella pneumonia. TTE showed left ventricular (LV) diastolic diameter of 6.2cm, LV ejection fraction 20-25%. He suffered rapid decompensation with mixed cardiogenic/septic shock requiring peripheral VA ECMO and Impella-CP placement. Course notable for brief cardiac arrest on hospital day (HD) 2, incidental diagnosis of COVID 19 on HD 14, conversion to VV ECMO on HD 15, and ECMO decannulation on HD 23. Repeat TTE prior to discharge showed normalization of biventricular function. Discussion(s): Despite resolution of refractory shock and normalization of biventricular function prior to discharge, the TTE finding of mild LV dilation and strong family history prompted outpatient pursuit of genetic testing which revealed a heterozygous TTRA mutation (val142ile). Work-up to assess cardiac involvement included: a 99m-technetium pyrophosphate scintigraphy found to be indeterminate, an aborted endomyocardial biopsy due to inability to smoothly advance a bioptome (presumably related to ECMO cannulation), and a cardiac MRI (pending at the time of this submission). If a cardiac phenotype is discovered, the patient will be started on targeted treatment of cardiac amyloid. Screening of first-degree family members has been initiated. Conclusion(s): Given the current state of under-diagnosis of genetic cardiomyopathies and its association with significant morbidity and mortality, it is prudent to consider genetic testing in young patients based on clinical history. Examples of clinical scenarios to prompt further testing include: anatomical findings (i.e. cardiac chamber enlargement, left ventricular hypertrophy), family history of cardiomyopathy, or clinical markers suggestive of alternative diagnoses (i.e. neuropathy, renal insufficiency, mediastinal lymphadenopathy). This thoughtful and algorithmic use of genetic testing may help improve long-term patient outcomes given improvements in both detection, family screening, and treatment for disease-specific cardiomyopathies.Copyright © 2022

A Rare Case Of Peripartum Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. Case presentation: A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Conclusion(s): Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain;however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.Copyright © 2022

The Stressed Heart: A Case Report of Takotsubo Cardiomyopathy in a Patient With Known Coronary Artery Disease.

Takotsubo cardiomyopathy and acute coronary syndrome are often clinically indistinguishable, making their differentiation challenging for physicians. We present a case of a 65-year-old female who presented with acute chest pain, shortness of breath, and a recent psychosocial stressor. This is a unique case in which our patient, with known history of coronary artery disease and recent percutaneous intervention, favored a misleading initial diagnosis of non-ST elevation myocardial infarction.

Long Term Sequale on COVID-19

Objective In 2021, accumulated coronavirus disease 2019 (COVID-19) confirmed cases exceeded 100 million worldwide. We sought the long term sequale on COVID-19. Design and Method Although there is a hope for vaccination, continuous infection is observed with case fatality rate over 2%. Patients with cardiovascular disease are more susceptible to COVID-19 and show more severe clinical course after the infection. COVID-19 related myocardial injury evidenced by increased troponin plasma levels occur in at least 10% of hospitalized patients and 25% to 35% or more, of critically ill patients. Patients with SARS-CoV-2 infection related cardiac complications are heart failure, arrhythmia, acute thrombosis, and stress induced cardiomyopathy. Results Myocardial injury is an important entity that cause long term sequale. The extent of the local tissue damage and cytokine storm triggered by the host immune response both contribute to the severity of the myocarditis. An exaggerated inflammatory response can be extremely fatal, and immunomodulators such as corticosteroids are considered in selected cases even though the efficacy and safety is questionable. Combined with these mechanisms related to a host immune response, multiple factors are responsible for the cardiac consequence of COVID-19, such as an oxygen supply and demand imbalance (with or without coronary artery disease), increased right ventricular afterload due to respiratory acidosis, hypoxemia and positive pressure ventilation. Even though it is difficult to discriminate all the possible mechanisms related to myocarditis, accordingly the effort to identify the dominant cause is necessary for the selection of the proper target treatment. Conclusions Substantial evidence has suggested a non-negligible incidence of cardiac injury related to COVID-19. Although the clinical significance and exact mechanisms are under investigation, we should be aware of the potentially fatal cardiac manifestations when dealing with patients with COVID-19. Long-term complications are also noticed from the recent publications and need further attention.

Covid-19 Induced Biventricular Takotsubo Cardiomyopathy

Background Takotsubo Cardiomyopathy (TTS) is a syndrome of transient LV dysfunction. Myocardial injury (MCI) has been reported in acute COVID-19 (C19) infections, however, the exact pathophysiology is unclear. Association of rising cardiac biomarkers with inflammatory markers suggests systemic inflammatory response in C19 infection in causing MCI. Case A 52-year-old AA male with history of HTN presents with complaint of worsening shortness of breath and atypical chest pain. Diagnosed with C19 and intubated due to respiratory failure. Chest pain workup included TTE which showed biventricular (BV) systolic dysfunction with apical ballooning and LVEF 25-30%. Left heart catheterization showed non-obstructing coronary disease. Repeat TTE 2 weeks later showed normal BV systolic function with LVEF greater than 55%. Decision-making BV TTS is associated with more hemodynamic instability than is isolated LV TTS. Mayo Clinic diagnostic criteria for TTS requires absence of obstructive CAD or plaque rupture. Rapid recovery of BV function is consistent with TTS with transient BV dysfunction. LV TTS is common in COVID-19 infections, but BV TTS is a less common complication of COVID. Conclusion Due to the propensity of C19 to cause hemodynamic instability it is important to not relate to a patient's instability to C19 alone. It is important to consider TTE in patients with C19, as the patient may be experiencing TTS. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Czech Cardiovascular Research and Innovation Day 2022

The proceedings contain 67 papers. The topics discussed include: role of endomyocardial biopsy in differential diagnosis of non- -ischemic cardiomyopathy;metformin treatment is associated with improved quality of life and outcome in patients with diabetes and advanced heart failure (HFREF);translational research in the field of inherited arrhythmias;same day discharge via a dedicated radial lounge - results of 1-year experience during the COVID-19 pandemic;functional assessment of microcirculation in takotsubo cardiomyopathy - a pilot study;an interplay of genetics and inflammation affecting left ventricular reverse remodeling in dilated cardiomyopathy;sildenafil inhibits pulmonary hypertension induced by left heart pressure overload in rats;predicting long-term survival after an ischemic stroke;and longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in the Czech population. are there any sex differences?.

Takotsubo cardiomyopathy presenting with QT prolongation and Torsade de pointes in the setting of coronavirus disease 2019.

Cardiovascular complications resulting from coronavirus disease 2019 (COVID-19) are occasionally observed; however, takotsubo cardiomyopathy (TCM) with QT prolongation and Torsade de pointes have rarely been reported. We herein present a case of TCM that occurred after QT prolongation and Torsade de pointes. A 58-year-old woman was admitted because of COVID-19 pneumonia. Seven days after admission, she had a sudden loss of consciousness without any precursor of cardiovascular disease. Monitoring electrocardiogram indicated Torsade de pointes and a prolonged QT interval. Emergency cardiac catheterization revealed the presence of TCM. She received favipiravir and steroids, followed by rehabilitation, which improved her condition. Routine electrocardiography screening is considered for patients with COVID-19 because asymptomatic TCM could be detected.

Takotsubo Cardiomyopathy and COVID-19: A Case Report and Literature Review.

Bckground: Takotsubo cardiomyopathy is characterized by transient regional ventricular abnormalities in the absence of coronary artery disease and is reported as a complication of COVID-19. Case Representation: It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock with an adverse effect on patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy. Conclusion: We also present a detailed review of the available literature regarding the relationship between COVID-19 and Takotsubo cardiomyopathy.

Cardiac Manifestations Associated With Coronavirus Disease: A Case Report

Abstract This study presents a 47-year-old female patient, with a history of diabetes, who contracted SARS-CoV-2 and exhibited cardiovascular complications.

Takotsubo syndrome and COVID-19: A systematic review.

Background and Aims: Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is characterized by acute and transient left ventricular dysfunction and has increased during the COVID-19 pandemic. Herein, we aim to review studies on TTS that were associated with COVID-19 infection, vaccine, and other COVID-19-related etiologies including psychosocial stressors. Methods: We systematically searched PubMed, EMBASE, and Scopus up to May 12, 2022. We included case reports, case series, and original articles that reported at least one TTS case associated with COVID-19, or TTS cases after receiving COVID-19 vaccines, or TTS cases secondary to psychological stress due to the COVID-19 pandemic. The quality assessment was conducted using the Joanna Briggs Institute checklist. Results: Sixty-seven articles including 102 cases were included. Hypertension was the most frequently accompanying comorbidity (N = 67 [65.6%]) and the mean left ventricular ejection fraction was 36.5%. Among COVID-19 patients, the in-hospital mortality rate was 33.3%. On the other hand, only one COVID-19-negative individual expired (2.3%). The most common presenting clinical symptom was dyspnea in 42 (73.6%) patients. the mean time interval from the first symptom to admission was 7.2 days. The most common chest imaging finding was ground-glass opacity which was reported in 14 (31.1%) participants. The most common abnormalities were T-wave inversion in 35 (43.2%) and ST-segment elevation in 30 (37%). Brain natriuretic peptide and troponin were elevated in 94.7% and 95.9% of participants, respectively. Conclusion: The TTS in patients with COVID-19 is almost rare, whereas it could lead to a great mortality and morbidity. An individual with COVID-19, especially an elderly woman, presented with dyspnea in addition to a rise in brain natriuretic peptide and troponin should be evaluated for TTS.

ATAK Complex (Adrenaline, Takotsubo, Anaphylaxis, and Kounis Hypersensitivity-Associated Coronary Syndrome) after COVID-19 Vaccination and Review of the Literature.

Anaphylactic events triggered by mRNA COVID-19 vaccines are neither serious nor frequent. Kounis syndrome is described as the concomitant occurrence of acute coronary events and hypersensitivity reactions induced by vasospastic mediators after an allergic event. Kounis syndrome caused by vaccines is very rare. Up to now, only a few cases of allergic myocardial infarction after mRNA COVID-19 vaccine administration have been reported. Takotsubo cardiomyopathy is a syndrome characterized by transient wall movement abnormalities of the left ventricular apex, mid-ventricle, or other myocardial distribution, usually triggered by intense emotional or physical stress. Takotsubo cardiomyopathy after COVID-19 vaccine administration has been reported, usually with a delayed onset. A new entity characterized by the association of adrenaline administration, Takotsubo cardiomyopathy, anaphylaxis, and Kounis hypersensitivity was recently described: the ATAK complex. Here, we report a case of Takotsubo cardiomyopathy that occurred together with an anaphylactic reaction to an mRNA COVID-19 vaccine that required the use of adrenaline. The timing of the allergic reaction and the referenced clinical symptoms could not exclude the idea that Kounis syndrome occurred. Therefore, we can assume the patient presented the ATAK complex. We believe that highlighting on this ATAK complex will aid the application of proper diagnostic, preventive and therapeutic measures.

TAKOTSUBO SYNDROME IN COVID-19 AND INFLUENZA INFECTIONS: A COMPARATIVE SYSTEMATIC REVIEW OF CLINICAL CHARACTERISTICS AND OUTCOMES

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Coronavirus disease 2019 (COVID-19) and influenza infections are associated with systemic inflammatory reactions that predispose to Takotsubo cardiomyopathy (TTS). Studies have investigated the epidemiology and clinical features of TTS in COVID-19 and influenza infection, however, there are limited data comparing TTS between patients with COVID-19 and influenza. METHODS: We searched PubMed/Medline, Web of Science, SCOPUS, EMBASE, and Google Scholar until November 1st, 2021, for case reports, case series, and observational cohort studies using these keywords: takotsubo syndrome/takotsubo cardiomyopathy, stress-induced cardiomyopathy, and broken heart syndrome combined with the terms COVID-19 and/or SARS-CoV-2, flu and/or influenza. All the published case reports included in the final analysis were in English and were categorized into patients with ‘COVID-19 + TTS’ and ‘Flu + TTS’. RESULTS: We identified 37 studies describing 64 patients with COVID-19+TTS and 10 case reports describing 10 patients with Flu + TTS. The mean age of patients in the COVID-19 + TTS was similar to the influenza group (69 years). Although women were more disproportionately affected by TTS in both groups, COVID-19 + TTS patients had a higher proportion of men than the Flu + TTS group (44% vs 30%) and previously reported incidence of TTS in men in the general population. Compared to patients with Flu + TTS, COVID-19 + TTS had a longer mean time from testing positive to developing TTS (7.3 days vs. 3.1 days), higher incidence rates of acute respiratory distress syndrome (77% vs. 40%), hypoxemic respiratory failure (86% vs. 60%), more likely to require invasive mechanical ventilation (63% vs. 40%) and higher in-hospital mortality rates (36%, n=23 vs 10%, n=1) CONCLUSIONS: Our systematic review highlights some important differences in the presentation and outcomes of TTS in patients with COVID-19 compared to seasonal influenza. Patients with COVID-19 + TTS had higher rates of respiratory complications and excess all-cause mortality compared to Flu + TTS. In contrast to the general population and patients infected with influenza, TTS tends to affect more men with COVID-19 infection. CLINICAL IMPLICATIONS: Hospitalized patients with COVID-19 who develop TTS appear to have a more severe disease course and poorer outcome compared to hospitalized patients with Flu+TTS. The study findings provide additional knowledge comparing complications between COVID-19 and influenza infections and may contribute to the continued efforts to manage the COVID-19 pandemic. DISCLOSURES: no disclosure on file for Temidayo Abe;No relevant relationships by Thomas Allingham No relevant relationships by Omovefe Edika No relevant relationships by Hammad Khalid No relevant relationships by Ifeoma Ogbuka No relevant relationships by Titilope Olanipekun No relevant relationships by Richard Snyder No relevant relationships by Abhinav Vedire No relevant relationships by Nicholas Wilson

A UNIQUE CASE OF SEVERE PULMONARY NOCARDIOSIS PRESENTING WITH ARDS AND CARDIOGENIC SHOCK

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Nocardiosis is a rare bacterial infection, which frequently affects immunocompromised patients. It can present as an acute, subacute, or chronic pulmonary infection with non-specific symptoms, such as fever, cough, dyspnea, weight loss, and hemoptysis. CASE PRESENTATION: A 34-year-old female with a history of chronic granulomatous disease and hidradenitis suppurativa on adalimumab presented to the ED with fever, shortness of breath, and productive cough of 2 days. Her vitals were T 101F, BP 66/48, HR 148, RR 42, and SPO2 94% on room air. On exam, she was cachectic, with bilateral crackles and rales in the right lung base. Extremities were cold, with trace pitting edema was present on bilateral lower extremities. COVID-19 PCR was negative. Despite fluid resuscitation, she remained hypotensive and was started on norepinephrine. Blood cultures were collected, and broad-spectrum antibiotics and an antifungal agent were initiated. Chest CT demonstrated bilateral multifocal consolidation with surrounding ground-glass opacities and complete consolidation of the right lower lobe. Due to worsening respiratory distress and tachypnea, and lack of improvement with non-invasive ventilation, she was intubated, placed on mechanical ventilation, and admitted to the Medical ICU. On hospital day 1, due to the patient's immunosuppression, unresolving shock, and radiographic findings, a bronchoscopy with bronchoalveolar lavage (BAL) was performed. On hospital day 2, a transthoracic echocardiogram showed LV ejection fraction of 20-25% with severe global hypokinesis of the LV. ACS workup had been unremarkable, with mildly elevated troponin and no ischemic changes on EKG. She was initiated on cardiac inotropes. On hospital day 3, BAL culture revealed Nocardia cyriacigeorgica. TMP-SMX and ceftriaxone were started for severe pulmonary nocardiosis. On hospital day 11, she was liberated from mechanical ventilation, and by hospital day 14, she was weaned off all pressors and inotropes. Approximately 4 weeks after admission, repeat TTE showed recovery of LV ejection fraction (55-60%) and she was discharged with a prolonged course of TMP-SMX and IV ceftriaxone, with duration to be determined at outpatient infectious disease follow-up. DISCUSSION: We discuss a unique case of severe pulmonary nocardiosis, presenting with ARDS and cardiogenic shock. To the best of our knowledge, this is the first case of a patient with pulmonary nocardiosis presenting with stress cardiomyopathy reported in the literature. While the pathophysiology is not well understood, theorized mechanisms include catecholamine excess, coronary artery spasm, microvascular dysfunction. CONCLUSIONS: This case highlights the need for a broad differential diagnosis in patients presenting with ARDS and cardiogenic shock and illustrates the value of clinical bronchoscopy in patients with unique presenting features. Reference #1: Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun;22(6):891-903;quiz 904-5. doi: 10.1093/clinids/22.6.891. PMID: 8783685. Reference #2: Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046. PMID: 15703419. Reference #3: Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, Koh Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005 Jul;128(1):296-302. doi: 10.1378/chest.128.1.296. PMID: 16002949. DISCLOSURES: no disclosure on file for D. Clark Files;No relevant relationships by Nisha Patel No relevant relationships by Meehir Shah

POSTINFECTIOUS COVID-19 ENCEPHALITIS RESPONSIVE TO PULSE-DOSE STEROIDS AND IV IMMUNOGLOBULINS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19). Post-infectious encephalitis secondary to SARS-CoV-2 may present with delirium, seizures, or transient comatose state. The mechanism of encephalitis in patients with COVID-19 is multifactorial. Cytokine release syndrome, a systemic hyperinflammatory condition, might have an integral part in the pathophysiology of this manifestation. Beneficial effects of pulse dose glucocorticoid therapy, with and without plasma exchange or IVIG, have been described. (1, 2) In this case report, we disclose a case of a young healthy male that presented with acute encephalopathy after 10 days of contracting SARS-CoV-2 and aim to discuss the potential role of IVIG and pulse dose steroid. CASE PRESENTATION: A 37-year-old previously healthy Caucasian man initially presented to urgent care with fatigue and generalized weakness and was diagnosed with acute COVID-19 infection through positive PCR. Four days later, he developed shortness of breath, syncope and vomiting. He was taken to the ER, where he had a witnessed seizure complicated by status epilepticus requiring endotracheal intubation for airway protection. He was then airlifted to our University Hospital. Upon arrival, labs were notable for elevated troponin, leukocytosis, and mildly elevated liver enzymes. An echocardiogram revealed stress induced (Takotsubo) cardiomyopathy. CT head was normal and continuous EEG showed focal electrographic seizures of left temporal onset. MRI of brain with/without contrast showed subtle areas of cortical diffusion hyperintensity involving left cerebral hemisphere including left posterior temporal lobe, lateral occipital lobe, posterior lateral frontal lobe and posterior lateral parietal lobe with subtle patchy areas of cortical enhancement on postcontrast T1-weighted images. CSF analysis was benign and CSF PCR for SARS-CoV-2 was negative. One gram daily IV methylprednisolone and IVIG therapy was given for total 5 days. On Day 2 of therapy, seizures subsided, and patient was successfully extubated after. Repeat MRI brain with/without contrast done after day of therapy showed improvement in previously demonstrated findings. He improved clinically and was discharged home on hospitalization day. DISCUSSION: Post-infectious COVID-19 encephalitis falls under the spectrum of disease described under neurological syndromes related to SARS-CoV-2 infection.(3) Diagnosis is based on Clinical presentation, positive COVID PCR on nasopharyngeal swab and Imaging demonstrating cortical enhancement on post contrast T1-weighted imaging. Out of various treatment options described in literature (1,2), our patient responded well to pulse dose steroids and IVIG therapy for 5 days. CONCLUSIONS: Careful selection of patients and therapies should be considered when post-infectious COVID-19 encephalitis is suspected. Reference #1: Cao A, Rohaut B, Le Guennec L, et al. Severe COVID-19-related encephalitis can respond to immunotherapy. Brain. 2020;143(12):e102. doi:10.1093/brain/awaa337 Reference #2: Pugin D, Vargas MI, Thieffry C, et al. COVID-19-related encephalopathy responsive to high-dose glucocorticoids. Neurology. 2020;95(12):543-546. doi:10.1212/WNL.0000000000010354 Reference #3: Al-Ramadan A, Rabab'h O, Shah J, Gharaibeh A. Acute and Post-Acute Neurological Complications of COVID-19. Neurol Int. 2021;13(1):102-119. Published 2021 Mar 9. doi:10.3390/neurolint13010010 DISCLOSURES: No relevant relationships by Ali Ahmad No relevant relationships by Varun Halani No relevant relationships by Michael Lasky No relevant relationships by Posan Limbu