COVID-19-ASSOCIATED MYOCARDITIS MIMICKING ST ELEVATION MYOCARDIAL INFARCTION

ABSTRACT

SESSION TITLE Medical Students/Residents' COVID-19 SESSION TYPE Med Student/Res Case Report PRESENTED ON October 18-21, 2020 INTRODUCTION: An outbreak of respiratory illness caused by a novel coronavirus started in China in 2019. The disease was termed coronavirus disease 2019 (COVID-19). The clinical course involved respiratory symptoms including dyspnea, cough, fatigue and complications related to pneumonia (1). While predominantly involving the respiratory tract, it has been shown to effect multiple other organs including the cardiovascular system (2). We present a case of COVID-19 associated focal myocarditis mimicking acute coronary syndrome. CASE PRESENTATION A 56-year-old man with presented to the emergency department with chest pain and dyspnea for one week. He also had for fatigue, non-productive cough and myalgia. He was hypoxic on presentation, requiring 3L of oxygen via nasal cannula. Physical exam was unremarkable. Chest x-ray was suggestive of increased interstitial prominence. A 12-lead-ECG was notable for normal sinus rhythm with ST elevations in the antero-lateral distribution (Figure 1). Initial Troponin I level was elevated at 8.6 ng/mL. His C-reative protein (CRP) was elevated at 160 mg/L and CBC showed mild absolute lymphopenia (lymphocyte count 0.6 bil/L). Rapid COVID-19 testing was obtained and the patient was treated appropriately for acute coronary syndrome with aspirin, unfractionated heparin and nitroglycerin infusion. He was taken to the catheterization lab for emergent coronary angiography which revealed no significant coronary disease (Figure 2). COVID-19 PCR returned positive and he was given supportive treatment in addition to azithromycin and hydroxychloroquine as part of COVID-19 regimen. He had marked improvement in symptoms over the next few days. DISCUSSION: Cardiac injury has been shown to occur in 8-12% of the patients affected by COVID-19 (3) and is associated with worse prognosis (1). The proposed mechanisms of injury include direct myocardial injury by the virus, systemic inflammation, demand ischemia and coronary thrombosis. Myocarditis associated with COVID-19 has been limited to few case reports. Our case highlights an atypical presentation of COVID-19 associated myocarditis. The focal ST segment elevations noted on the ECG along with clinical symptoms were suggestive of a concomitant acute coronary syndrome despite other clinical symptoms suggestive of COVID-19. ECG only has about 47% sensitivity for myocarditis and is characterized usually by non-specific ST-T changes. Echocardiographic findings are variable and non-specific. Segmental wall motion abnormalities mimicking myocardial infarction can be observed as seen in our patient. Although the gold standard for diagnosis is myocardial biopsy, cardiac MR is being increasingly utilized as a non-invasive test. Due to high clinical suspicion and rapid improvement in symptoms, these tests were not pursued and a clinical diagnosis was made. CONCLUSIONS: We report an atypical presentation of myocarditis associated with COVID-19. Reference #1 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223)497-506. Reference #2 Akhmerov A, Marban E. COVID-19 and the Heart. Circulation research. 2020;126(10)1443-55. Reference #3 Lippi G, Plebani M. Laboratory abnormalities in patients with COVID-2019 infection. Clinical chemistry and laboratory medici ne. 2020. DISCLOSURES No relevant relationships by NIKHIL AGRAWAL, source=Web Response no disclosure on file for Nawfal Al-khafaji;No relevant relationships by Syed Mustafa, source=Web Response No relevant relationships by Amir Shahbaz, source=Web Response No relevant relationships by Meer Zafar, source=Web Response