MARKEDLY ELEVATED TROPONIN WITH COVID-19 PNEUMONIA WITHOUT ACUTE CORONARY SYNDROME

ABSTRACT

TOPIC Chest Infections TYPE Medical Student/Resident Case Reports INTRODUCTION: COVID infection can present with diverse manifestations. We present an interesting case of very high troponin elevation in patient with COVID infection without obvious reason for troponin elevation. CASE PRESENTATION A 66-year-old man with history of HTN, DM2, CAD (CABG in 2009, percutaneous vascularization of RCA with multiple DES in 2018), NSTEMI- 1 year ago, PVD, status post left BKA, ESRD on HD presented with 1 week of watery diarrhea after being tested positive for COVID. He denied chest pain, had minimal SOB. He received first dose of COVID vaccine 2 weeks prior. Vital signs afebrile, BP 145/68 mmhg, HR 75 beats/min, RR 20/min, oxygen saturation 90% on RA and 96% on 3L of O2 via NC. PE R- IJ permanent catheter, L- BKA, lungs clear. Labs COVID PCR assay (+), D dimer 359 D-DU ng/ml, LDH 330 U/l, ferritin 3207 ng/ml, CRP quant 87 ml/l, SARS-CoV-2 Ig G (RBD) 1.14 S/CO, SARS-COV-2 IgM (Beckman) 2.56. troponin (AccuTnI) 13.46 ng/ml, CPK normal, Cr 7.5 (at the baseline), EKG - sinus rhythm, left axis deviation, negative T waves in lateral leads and ST depression up to 1 m in anterior leads, no changes from old EKG, CXR - Increased b/l pulmonary opacities compatible with atypical/viral pneumonia. The most recent ECHO 1 year ago – mild LV dysfunction with thin and akinetic inferior and basal posterior walls, LVEF 50%. Patient was already on aspirin, plavix, statin and that treatment was continued during hospital course. COVID pneumonia was treated with dexamethasone and convalescent plasma versus placebo (VA Cures- 1 Trial). His hospital stay was uneventful, he remained hemodynamically stable and asymptomatic and was discharged home DISCUSSION: Our patient has known history of CAD and ESRD which are well known cause for elevated troponin. However his Cr level was at his baseline and his previous troponin levels were never this high even when he had NSTEMI, it was only 1.44 ng/ml. During this admission with Covid infection his troponin level was as high as 13.46 ng/ml and trended down to 4.15 ng/ml on discharge, his baseline level of troponin is 0.03-0.88 ng/ml. Reasons for such a high level of troponin can be due to Type II MI or myocarditis. In the settings of COVID infection it has been suggested that troponemia can be due to microvascular damage occurring in the heart with perfusion defects, vessel hyperpermeability, vasospasm and high cytokine levels may represent the key player of myocardial injury (1). Our patient did not have a very severe form of COVID pneumonia that required intubation in fact, he was saturating well on minimal oxygen requirements. He remained asymptomatic with no new interval EKG changes or any other signs of acute coronary syndrome (ACS). CONCLUSIONS: Serum Troponin can be significantly elevated in the setting of COVID infection and in the absence of ACS. REFERENCE #1 Reference #1 Tersalvi G, Vicenzi M, Calabretta D, Biasco L, Pedrazzini G, Winterton D. Elevated Troponin in Patients With Coronavirus Disease 2019 Possible Mechanisms. J Card Fail. 2020;26(6)470-475. doi10.1016/j.cardfail.2020.04.009 DISCLOSURES no disclosure on file for Moses Bachan;no disclosure on file for Zinobia Khan;No relevant relationships by Dileep Kumar, source=Web Response No relevant relationships by Mirjana Petrovic Elbaz, source=Web Response