key: cord-0874848-vrpze7tr
authors: Amir, Muzakkir; Djaharuddin, Irawaty; Sudharsono, Albert; Ramadany, Sri
title: COVID-19 Concomitant Infective Endocarditis: A-Case Report and Review of Management
date: 2020-06-20
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.06.061
sha: a7b9009e4886e72a0188c283f97abf2b64e559ce
doc_id: 874848
cord_uid: vrpze7tr

Abstract Novel coronavirus disease (2019-nCoV) has emerged as pandemic and public health crisis across the world. High infectivity and spread rapidly, this disease severity escalating in certain population especially in patients with pre-existing Cardiovascular Disease (CVD). In developing countries, Infective Endocarditis (IE) is still a scourge in patients with Rheumatic Heart Disease (RHD). We report a patient with the diagnosis of infective endocarditis concomitant COVID-19 and reporting the main outcome, diagnostic, and management of this disease

On March 11, 2020, World Health Organization (WHO) has declared the global pandemic caused by Coronavirus Disease 2019 (COVID-19). Since then, this disease has affected more than 3 million people in over 200 countries or regions worldwide. Several studies including one meta-analysis reported cardiovascular involvement due to this infection. 1 Moreover, it should not be forgotten that the diagnosis of COVID-19 does not imply the exclusion of other.

The incidence of Rheumatic fever (RF) and RHD has been decreasing since the early 1900s, they continue to develop predominantly in developing countries particularly within low socioeconomic and inadequate education population with more than 15 million cases of RHD reported worldwide. Infective Endocarditis remains a serious threat to any patient with RHD, even in this therapeutic advance decade the mortality and morbidity in developing countries remains high. 2 Moreover, selection of antibiotic therapy in COVID-19 and culture-negative infective endocarditis patients should be attentive due to complication and accompanying disease.

J o u r n a l P r e -p r o o f Cardiovascular disease is the most common comorbidity found in COVID-19 patients.

The clinical manifestation of Infective endocarditis and COVID-19 are challenging, both diseases could develop fever, chills, dyspnea, fatigue, cough and myalgia. 3 However, COVID-19 concomitant infective endocarditis will be found in developing countries and initial screening will be vague. We report a case of COVID-19 with the appearances of shortness of breath as example to point out that SARS-CoV-2 may accompany various other clinical conditions. Every physician especially in developing countries should be aware and consider echocardiography when evaluating patients with COVID-19.

A 61-year-old male was referred to cardiac center with chief complaint shortness of breath 2 day before admission, history of fever 38,4°C, chest discomfort and minimal dry cough. He had symptoms such as dyspnea on effort and orthopnea 1 year before, but never got a comprehensive medical examination. He had history of hypertension and previous smoking history. On March 8, 2020, 2 weeks before admitted, he just arrived from Saudi Arabia after (Fig 2b.) We performed a nasopharyngeal swab re-examination twice on 5 th and 8 th day hospitalization and showed a negative result therefore the patient was discharged on the 10 th day of hospitalization.

As the current world pandemic develops, COVID-19 infection concomitant with other disease will be common in daily practice. Our Case, the patient presented with shortness of breath, fever, fatigue, and dry cough. He also had history of heart failure which complicate us to distinguish clinically between a cardiac or respiratory etiology. 4 However, we still put suspicion of COVID-19 on this patient, since some patients develop cardiovascular manifestation such as angina chest pain, shortness of breath, and arrhythmias. 5 Trans-thoracic echocardiography (TTE) results were considered as RHD complicated IE. We established IE based on Modified Duke Criteria along with 3 minor criteria (osler node lesions, splinter hemorrhages, and fever). 6 Negative culture results in our center, however, probably resulted from previous administration of antibiotics in referral hospital. We couldn't proceed to investigate the microorganism caused IE due to serologic testing and polymerase-J o u r n a l P r e -p r o o f chain-reaction (PCR) using blood or valve biopsies could not be done in this pandemic era in our center. Moreover, based on TTE we found severe mitral regurgitation with jet length ≥2 cm, velocity ≥ 3 m/s and moderate aorta regurgitation seen in two views, these TTE findings confirmed the patient had suffered from RHD. 7 We discussed the relationship between COVID-19 and IE to be refuted since the vegetation is a process that initiated through a transient bacteremia, followed by binding and adherence to damaged endothelium and, encased in a platelet/fibrin matrix. Thromboplastin being released by tissue factor from damaged endothelium causing platelet aggregation and cleavage of fibrinogen to fibrin. 8 We also believed to confirmed the role of viruses in endocarditis is quite complex, we couldn't find any reported case directly prove virus as the causative agent. 9 At present there is limited evidence from literature in management patients with COVID-19 and IE. The concerns about the safety of ACE-I arise from the observation during hospitalized whether ACE-I will increase the severity of the infection. We decide to hold the ACE-I on the 4 th day hospitalization since the patient developed worsen cough. We continue to start Angiotensin Receptor Blocker (ARB) when the patient status clinically improve until discharged, data from human studies support the treatment of ARB or ACE-I regardless ACE2 protein theory. 10 Seeing the positive effects of the use of this drug in patients with hypertension, heart failure, valvular heart disease and chronic kidney disease we will continue to prescribe ARB in our patient.

Oseltamivir, inhibitor viral neuroamidase, was given in this patient. A decision to administer oseltamivir for compassionate use was based on the availability during that time. 11 We could not prescribe other antiviral drugs during that time, since it is the only available drug during that time.

This patient also suffered from hypervolume low osmolarity hyponatremia accompanied by alteration of kidney function, therefore we administered 3% sodium chloride but unfortunately didn't respond. We decided to add Tolvaptan, a diuretic that works by binding to V2 receptors, interfering with aquaporin 2 movement to the luminal side of cortical collection channel cells through cAMP activation and inhibiting water reabsorption. This drug provides a protective effect on kidney function because it provides a diuretic effect without activating the renin-angiotensin system which might be beneficial in COVID-19 patients. 1213

The guidelines for antibiotic administration in IE culture-negative are still unclear.

According to the Journal of Antimicrobial Chemotherapy, the antimicrobial protocol in unknown microorganism negative culture IE includes four intravenous antimicrobial agents, such as: amoxicillin, vancomycin, gentamicin, and amphotericin B. 14 The kidney function of this patient was not improved with drug administration and adequate rehydration during hospitalization. Giving aminoglycoside antibiotics such as gentamicin will aggravate the patient's kidney function.

In patient with heart failure and IE related rheumatic heart disease, surgery in the best option, though in a pandemic situation it is not possible to perform cardiac surgery in our center. Until now, there aren't any literature that supports or rejects heart valve surgery in COVID-19 patients. According to guideline, we decided to hold any prophylactic antibiotic in our patient, since he won't receive any medical procedures in the near future. 15

Among the reported cases of COVID-19, we report the first case managing COVID-19 case with IE. Management of IE could be difficult since there are several limitations during J o u r n a l P r e -p r o o f this pandemic. This case illustrates the potential severity of complications and challenges in developing standard management for the disease given that much remains unknown about COVID-19 management in special populations. Full routine cardiac examination screening should be performed in patients with COVID-19. We hope this case will expand the funding of knowledge and a wise approach to the next case in order to provide.

Ethical Approval: The patient has given permission and informed consent for the publication of this case report. 

Prevalence of Underlying Diseases in Hospitalized Patients with COVID-19: a Systematic Review and Meta-Analysis

The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century The international collaboration on Endocarditis-prospective cohort study

The Variety of Cardiovascular Presentations of COVID-19

Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis

Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis

World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease-an evidence-based guideline

Formation of Vegetations during Infective Endocarditis Excludes Binding of Bacterial-Specific Host Antibodies to Enterococcus faecalis

Viral endocarditis or simple viral disseminated infection?

Risks of ACE inhibitor and ARB usage in COVID-19: evaluating the evidence

Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A Review

Tolvaptan, a selective oral vasopressin V2 receptor antagonist, ameliorates podocyte injury in puromycin aminonucleoside nephrotic rats

Effects of tolvaptan on systemic and renal hemodynamic function in dogs with congestive heart failure

Evaluation of empirical treatment for blood culture-negative endocarditis

ESC Guidelines for the management of infective endocarditis

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.