Challenging differential diagnosis
Richa Purohit, Arjun Kanwal, Anil Pandit, Bhavin M. Patel, Glenn Robert Meininger, Jeffrey Jay Brown, Antony George Kaliyadan, Aditya Saini
Internal Medicine Residency Program, MedStar Health, Baltimore, MD, USA
Am J Case Rep 2020; 21:e925554
Available online: 2020-05-21
Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness. However, with rising numbers of cases, multiple reports of cardiovascular manifestations have emerged. We present a case of COVID-19 infection complicated by myopericarditis and tamponade requiring drainage.
CASE REPORT: An 82-year-old woman with multiple comorbidities presented with five days of productive cough, fever with chills, and intermittent diarrhea. She tested positive for COVID-19. Index EKG revealed new diffuse T-wave inversions and a prolonged QT interval (>500 ms). Troponin was mildly elevated without any anginal symptoms. Hydroxychloroquine and azithromycin were not initiated due to concerns about QT prolongation. The echocardiogram revealed preserved left ventricular (LV) function, a small global pericardial effusion, and apical hypokinesis. Serial echocardiograms revealed an enlarging circumferential pericardial effusion with pacemaker wire reported as ‘piercing’ the right ventricular (RV) apex alongside early diastolic collapse of the right ventricle, suggesting echocardiographic tamponade. Chest CT revealed extension of the RV pacemaker lead into the pericardial fat. Interestingly, on comparison with a previous chest CT from 2019, similar lead positions were confirmed. Pericardiocentesis was performed with removal of 400 cc exudate.
CONCLUSIONS: Acute myopericarditis and pericardial effusion can occur in COVID-19 infection, even in the absence of severe pulmonary disease. This case highlights the importance of awareness of rare cardiac manifestations of COVID-19 in the form of acute myopericarditis and cardiac tamponade and their early diagnosis and management.
Keywords: Cardiac Tamponade, COVID-19, myocarditis, Pericarditis