key: cord-0948213-ytk3jcb4
authors: Dabbagh, Mohammed F.; Aurora, Lindsey; D’Souza, Penny; Weinmann, Allison J.; Bhargava, Pallavi; Basir, Mir B.
title: Cardiac Tamponade Secondary to COVID-19
date: 2020-04-23
journal: JACC. Case reports
DOI: 10.1016/j.jaccas.2020.04.009
sha: 3b0347a160671ba64856f0559d3ebcb565129a5a
doc_id: 948213
cord_uid: ytk3jcb4

Abstract A 67-year-old female presented with upper respiratory symptoms and was diagnosed with COVID-19. She was found to have a large hemorrhagic pericardial effusion with echocardiographic signs of tamponade and mild left ventricular impairment. Clinical course was complicated by development of Takotsubo cardiomyopathy. She was treated with pericardiocentesis, colchicine, corticosteroids and hydroxychloroquine with improvement in symptoms.

COVID-19 = coronavirus disease 2019 cTnI = cardiac troponin I ECG = electrocardiogram LDH = lactate dehydrogenase LVEF = left ventricular ejection fraction NICM = non-ischemic cardiomyopathy RR = reference range TTE = transthoracic echocardiogram TTC = Takotsubo cardiomyopathy SARS-CoV-2 = Severe acute respiratory syndrome coronavirus 2 Abstract: A 67-year-old female presented with upper respiratory symptoms and was diagnosed with COVID-19. She was found to have a large hemorrhagic pericardial effusion with echocardiographic signs of tamponade and mild left ventricular impairment. Clinical course was complicated by development of Takotsubo cardiomyopathy. She was treated with pericardiocentesis, colchicine, corticosteroids and hydroxychloroquine with improvement in symptoms.

A 67-year-old female presented to the emergency department with cough, mild shortness of breath and left shoulder pain. Physical exam and radiographic imaging of the chest were unremarkable (Figure 1) . A nasopharyngeal swab was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction. She was discharged home due to mild symptoms.

One week after her initial presentation, she presented with worsening dyspnea and orthopnea.

Physical exam was pertinent for a blood pressure of 118/82 mmHg, heart rate 122 beats/min, respiratory rate 24 breaths/min, temperature 36.8 °C, a normal oxygen saturation on room air, distant heart sounds and rales at the lung bases bilaterally.

The patient has a history of non-ischemic cardiomyopathy (NICM) with left ventricular ejection fraction (LVEF) of 15%, diagnosed in 2018 and managed with guideline directed medical therapy with improvement in her LVEF to 40%. She is not prescribed antiplatelet agents or anticoagulants and has no history of malignancy or coagulopathy.

The differential diagnosis includes evolving coronavirus disease 2019 (COVID-19) pneumonia, acute on chronic heart failure exacerbation, acute coronary syndrome, acute pulmonary embolism, myocarditis, and pericardial disease.

Chest x-ray and computed tomography angiogram obtained one week prior to admission were negative for pneumonia or pulmonary embolism. Upon re-presentation to the hospital, chest xray demonstrated an enlarged cardiac silhouette and electrocardiogram (ECG) revealed low voltage in the limb leads with nonspecific ST changes ( Figure 2 ). Laboratory testing demonstrated normal levels of high sensitivity cardiac troponin I (cTnI) (<18 ng/L; reference range (RR) <19 ng/L) and mildly elevated brain natriuretic peptide (54 pg/mL; RR <50 pg/mL).

Transthoracic echocardiogram (TTE) (Video 1, 2) revealed a large pericardial effusion circumferentially around the entire heart with signs of early right ventricular diastolic collapse, dilated but collapsing inferior vena cava, and mitral valve inflow variation of 31% on pulse wave Doppler. LVEF was mildly reduced at 40%, with no regional wall motion abnormalities, similar to TTE one year ago.

Given the patient's worsening symptoms, rapid expansion of the effusion over 1 week and early echocardiographic findings of tamponade, we elected to proceed with pericardiocentesis. The patient could not tolerate lying flat due to severe coughing spells and emesis, so she underwent elective intubation and was taken to the cardiac catheterization laboratory. Pericardiocentesis yielded 800 mL of exudative bloody fluid [fluid lactate dehydrogenase (LDH) 1,697 IU/L, pericardial fluid LDH/serum LDH >0.6]. Fluid cytology was negative for malignant cells. Acidfast bacilli smear was negative and there was no growth on cultures. Samples of the fluid were frozen in an effort to test the presence of SARS-CoV-2 which is currently not available in our center. Serum autoimmune workup was negative. In the absence of a history of malignancy, chest trauma, or coagulopathy, we suspected the hemorrhagic effusion to be secondary to COVID-19. Treatment was started with hydroxychloroquine along with colchicine and glucocorticoids given elevated serum inflammatory markers: C-reactive protein (15.9 mg/dL; RR <0.5 mg/dL), ferritin (593 ng/mL; RR 11-307 ng/mL), D-dimer (6.52 µg/mL; RR <0.68 µg/mL) and interlukin-6 (8 pg/mL; RR ≤5 pg/mL). Serial TTEs demonstrated resolution of the pericardial effusion, however, the patient was found to have new hypokinesis of the apical and periapical walls concerning for Takotsubo cardiomyopathy (TTC) (Video 3). This coincided with a rise in cTnI levels to 2,410 (ng/L) and deep T wave inversions in precordial leads (V2-V6) ( Figure 3 ). The patient did not develop any chest pain or worsening dyspnea. On the contrary, she reported improvement of dyspnea and was subsequently discharged from the hospital.

SARS-CoV-2 is the novel virus that causes COVID-19 (1). Early studies from Wuhan, China demonstrated that patients commonly develop fever, upper respiratory symptoms and pneumonia (2) . As the disease spread globally, reports of extrapulmonary manifestations have been frequently identified, however, pericardial involvement has been rarely reported (3, 4) . Herein, we report the case of a patient who developed large symptomatic hemorrhagic pericardial effusion causing cardiac tamponade. There were no initial signs of cardiac injury or myocardial involvement as demonstrated by the absence of cTnI elevation or wall motion abnormalities on TTE. In fact, her symptoms were relatively mild until the development of pericardial effusion. Viral infections are a common cause of pericarditis and typically entail a benign clinical course (5) . Hemorrhagic pericardial effusions have been less commonly associated with viral infections but have been reported in Coxsackievirus (6) . It is hypothesized that viruses cause pericardial inflammation via direct cytotoxic effects and/or via immune-mediated mechanisms (5) . COVID-19 has been reported to trigger an exaggerated systemic inflammatory response in certain patients, however, details of this response are not fully understood (3) . It is plausible that COVID-19, like other viral infections, elicits an inflammatory response leading to pericarditis and subsequent effusion, however, the exact mechanism is unclear. Hemorrhagic effusions have also been reported in other inflammatory states such as Dressler's syndrome, which is thought to result from an immune complex deposition and a subsequent inflammatory cascade post myocardial infarction (7, 8) .

After pericardiocentesis, our patient developed TTC as evident by TTE, ECG findings and cTnI elevation. TTC is a stress induced cardiomyopathy characterized by transient apical ballooning with regional wall motion abnormalities that occur in association with identifiable emotional or physical stressors including infections (9) . The Mayo Clinic proposed the following diagnostic criteria for diagnosis of TTC: transient segmental left ventricular systolic dysfunction, absence of obstructive coronary artery disease, new ECG abnormalities or modest cardiac troponin elevation and absence of pheochromocytoma or myocarditis (9) . Our patient met these diagnostic criteria clinically and echocardiogram was consistent with apical ballooning. Cardiac magnetic resonance would have definitively ruled out the presence of myocarditis, however, it was not performed as the patient's condition continued to improve and to further avoid non-essential medical testing to minimize spread of the disease. Acute coronary syndrome (ACS) was unlikely as coronary angiography from two years ago showed no significant coronary artery disease and the patient demonstrated no symptoms of ACS. While TTC has been widely reported in the setting of severe bacterial infections, cases of TTC attributed to viral infections such as influenza are rare (10) . In our case, troponin elevation and apical hypokinesis occurred only after intubation and pericardiocentesis, therefore stress from these procedures is also a possible etiology.

Our patient received hydroxychloroquine and low dose glucocorticoids as per our institutional treatment protocol, however, it is important to note that currently there is no proven data for efficacy of this regimen for COVID-19. We also treated our patient with colchicine given 6 elevated inflammatory makers. The patient was continued on guideline directed medical therapy for NICM including beta blockers, angiotensin receptor blocker, and spironolactone. Repeat TTE prior to discharge demonstrated stable ejection fraction and resolution of pericardial effusion.

We report a rare presentation of COVID-19 infection complicated by a large symptomatic hemorrhagic pericardial effusion and development of Takotsubo cardiomyopathy.

• Recognize that COVID-19 can have extrapulmonary manifestations which can be readily identified with physical examination and simple diagnostic studies

• Identify COVID-19 as a potential etiology of hemorrhagic pericardial effusion 

Naming the coronavirus disease (COVID-19) and the virus that causes it

Clinical Characteristics of Coronavirus Disease 2019 in China

Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

COVID-19): A Systematic Review of Imaging Findings in 919 Patients

ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of

Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)

Cardiac tamponade caused by acute coxsackievirus infection related pericarditis complicated by aortic stenosis in a hemodialysis patient: a case report

Cardiac tamponade in Dressler's syndrome. Case report

Images in clinical medicine. Cardiac tamponade in Dressler's syndrome

Diagnosis of Takotsubo cardiomyopathy