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

Aurora, Lindsey

Basir, Mir B

Bhargava, Pallavi

D\u27Souza, Penny L

Dabbagh, Mohammed F

Weinmann, Allison J

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Cardiology Articles Cardiology/Cardiovascular Research 4-23-2020 Cardiac Tamponade Secondary to COVID-19 Mohammed F. Dabbagh Henry Ford Health System, MDabbag1@hfhs.org Lindsey Aurora Henry Ford Health System, LAURORA1@hfhs.org Penny L. D'Souza Henry Ford Health System, pdsouz1@hfhs.org Allison J. Weinmann Henry Ford Health System, aweinma1@hfhs.org Pallavi Bhargava Henry Ford Health System, pbharga1@hfhs.org See next page for additional authors Follow this and additional works at: https://scholarlycommons.henryford.com/cardiology_articles Recommended Citation Dabbagh MF, Aurora L, D'Souza P, Weinmann AJ, Bhargava P, and Basir MB. Cardiac Tamponade Secondary to COVID-19. JACC Case Rep 2020. This Article is brought to you for free and open access by the Cardiology/Cardiovascular Research at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Cardiology Articles by an authorized administrator of Henry Ford Health System Scholarly Commons. Authors Mohammed F. Dabbagh, Lindsey Aurora, Penny L. D'Souza, Allison J. Weinmann, Pallavi Bhargava, and Mir B. Basir This article is available at Henry Ford Health System Scholarly Commons: https://scholarlycommons.henryford.com/cardiology_articles/562 HEART FAILURE AND IMAGINGCASE REPORT: CLINICAL CASECardiac Tamponade Secondaryto COVID-19Mohammed F. Dabbagh, MD,a Lindsey Aurora, MD,a Penny D’Souza, DO,a Allison J. Weinmann, MBBS,bPallavi Bhargava, MD,b Mir B. Basir, DOaABSTRACTA 67-year-old woman presented with upper respiratory symptoms and was diagnosed with coronavirus disease-2019(COVID-19). She was found to have a large hemorrhagic pericardial effusion with echocardiographic signs of tamponadeand mild left ventricular impairment. Clinical course was complicated by development of takotsubo cardiomyopathy.She was treated with pericardiocentesis, colchicine, corticosteroids, and hydroxychloroquine, with improvement insymptoms. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2020;2:1326–30) © 2020 The Authors.Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access articleunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).HISTORY OF PRESENTATIONA 67-year-old woman presented to the emergencydepartment with cough, mild shortness of breath, andleft shoulder pain. Physical exam and radiographicimaging of the chest were unremarkable (Figure 1). Anasopharyngeal swab was positive for severe acuterespiratory syndrome-coronavirus-2 (SARS-CoV-2) byreverse transcription polymerase chain reaction. Shewas discharged home due to mild symptoms.One week after her initial presentation, shepresented with worsening dyspnea and orthopnea.Physical exam was pertinent for a blood pressure of118/82 mm Hg, heart rate of 122 beats/min, respi-ratory rate of 24 breaths/min, temperature of36.8C, normal oxygen saturation on room air,distant heart sounds, and rales at the lung basesbilaterally.PAST MEDICAL HISTORYThe patient had a history of nonischemic cardiomy-opathy with left ventricular ejection fraction (LVEF)of 15%, diagnosed in 2018 and managed withguideline-directed medical therapy with improve-ment in her LVEF to 40%. She had not been not pre-scribed antiplatelet agents or anticoagulants and hadno history of malignancy or coagulopathy.DIFFERENTIAL DIAGNOSISThe differential diagnosis included evolving corona-virus disease-2019 (COVID-19) pneumonia, acute-on-LEARNING OBJECTIVES To recognize that COVID-19 can haveextrapulmonary manifestations, which canbe readily identified with physical examina-tion and simple diagnostic studies. To identify COVID-19 as a potential etiologyof hemorrhagic pericardial effusion.ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.04.009From the aHeart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; and the bDepartment of Infectious Disease, HenryFord Hospital, Detroit, Michigan. The authors have reported that they have no relationships relevant to the contents of this paperto disclose.The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in-stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visitthe JACC: Case Reports author instructions page.Manuscript received April 14, 2020; accepted April 16, 2020.J A C C : C A S E R E P O R T S V O L . 2 , N O . 9 , 2 0 2 0ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E AM E R I C A NC O L L E G E O F C A R D I O L O G Y F O U N DA T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E RT H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .chronic heart failure exacerbation, acute coronarysyndrome, acute pulmonary embolism, myocarditis,and pericardial disease.INVESTIGATIONSChest x-ray film and computed tomography angiogramobtained 1 week prior to admission were negative forpneumonia or pulmonary embolism. Upon represen-tation to the hospital, chest x-rayfilm demonstrated anenlarged cardiac silhouette and electrocardiography(ECG) revealed low voltage in the limb leads withnonspecific ST-segment changes (Figure 2). Laboratorytesting demonstrated normal levels of high-sensitivitycardiac troponin I (cTnI) (<18 ng/l; reference range[RR]: <19 ng/l) and mildly elevated brain natriureticpeptide (54 pg/ml; RR: <50 pg/ml). Transthoracicechocardiography (TTE) (Videos 1 and 2) revealed alarge pericardial effusion circumferentially around theentire heart with signs of early right ventricular dia-stolic collapse, dilated but collapsing inferior venacava, and mitral valve inflow variation of 31% onpulsed wave Doppler. LVEF was mildly reduced at40%, with no regional wall motion abnormalities,similar to TTE 1 year prior.MANAGEMENTGiven the patient’s worsening symptoms, rapidexpansion of the effusion over 1 week, andearly echocardiographic findings of tamponade, weelected to proceed with pericardiocentesis. The pa-tient could not tolerate lying flat because ofsevere coughing spells and emesis, soshe underwent elective intubation and wastaken to the cardiac catheterization labora-tory. Pericardiocentesis yielded 800 ml ofexudative bloody fluid (fluid lactatedehydrogenase [LDH] 1,697 IU/l, pericardialfluid LDH/serum LDH >0.6). Fluid cytologywas negative for malignant cells. Acid-fastbacilli smear was negative, and there was nogrowth on cultures. Samples of the fluidwere frozen in an effort to test the presenceof SARS-CoV-2, which is currently not avail-able in our center. Serum autoimmune work-up was negative. In the absence of a historyof malignancy, chest trauma, or coagulop-athy, we suspected the hemorrhagic effusionto be secondary to COVID-19. Treatment wasstarted with hydroxychloroquine along with colchi-cine and glucocorticoids given elevated serum in-flammatory markers: C-reactive protein (15.9 mg/dl;RR: <0.5 mg/dl), ferritin (593 ng/ml; RR: 11 to 307 ng/ml), D-dimer (6.52 mg/ml; RR: <0.68 mg/ml),and interlukin-6 (8 pg/ml; RR: #5 pg/ml). Serial TTEdemonstrated resolution of the pericardial effusion;however, the patient was found to have new hypo-kinesis of the apical and periapical wallsconcerning for takotsubo cardiomyopathy (TTC)(Video 3). This coincided with a rise in cTnI levels to2,410 (ng/l) and deep T-wave inversions inprecordial leads (V2 to V6) (Figure 3). The patient didnot develop any chest pain or worsening dyspnea. Onthe contrary, she reported improvement ofFIGURE 1 Imaging on Initial PresentationChest x-ray film (left) and chest computed tomography (right) showing no acute lung disease. Cardiac silhouette appears normal.AB BR E V I A T I O N SAND ACRONYM SCOVID-19 = coronavirusdisease-2019cTnI = cardiac troponin IECG = electrocardiographyLDH = lactate dehydrogenaseLVEF = left ventricularejection fractionRR = reference rangeSARS-CoV-2 = severe acuterespiratory syndrome-coronavirus-2TTC = takotsubocardiomyopathyTTE = transthoracicechocardiographyJ A C C : C A S E R E P O R T S , V O L . 2 , N O . 9 , 2 0 2 0 Dabbagh et al.J U L Y 1 5 , 2 0 2 0 : 1 3 2 6 – 3 0 Cardiac Tamponade Secondary to COVID-191327FIGURE 2 Chest X-Ray Film and Electrocardiography on Second Presentation(Left) Chest x-ray film: enlarged cardiac silhouette. (Right) Electrocardiography: normal sinus rhythm with low-voltage QRS complex in limb leads and nonspecific ST-segment changes in precordial leads.FIGURE 3 Electrocardiogram After PericardiocentesisElectrocardiography: sinus rhythm with deep T-wave inversions in precordial leads V2 to V6.Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . 2 , N O . 9 , 2 0 2 0Cardiac Tamponade Secondary to COVID-19 J U L Y 1 5 , 2 0 2 0 : 1 3 2 6 – 3 01328dyspnea and was subsequently discharged from thehospital.DISCUSSIONSARS-CoV-2 is the novel virus that causes COVID-19(1). Early studies from Wuhan, China, demonstratedthat patients commonly develop fever, upper respi-ratory symptoms, and pneumonia (2). As the diseasehas spread globally, reports of extrapulmonary man-ifestations have been frequently identified; however,pericardial involvement has been rarely reported(3,4). Here, we report the case of a patient whodeveloped large symptomatic hemorrhagic pericar-dial effusion causing cardiac tamponade. There wereno initial signs of cardiac injury or myocardialinvolvement, as demonstrated by the absence of cTnIelevation or wall motion abnormalities on TTE. Infact, her symptoms were relatively mild until thedevelopment of pericardial effusion.Viral infections are a common cause of pericarditisand typically entail a benign clinical course (5). Hem-orrhagic pericardial effusions have been lesscommonly associated with viral infections but havebeen reported in coxsackievirus (6). It is hypothesizedthat viruses cause pericardial inflammation via directcytotoxic effects or via immune-mediated mecha-nisms (5). COVID-19 has been reported to trigger anexaggerated systemic inflammatory response incertain patients; however, details of this response arenot fully understood (3). It is plausible that COVID-19,similar to other viral infections, elicits an inflamma-tory response, leading to pericarditis and subsequenteffusion; however, the exact mechanism is unclear.Hemorrhagic effusions have also been reported inother inflammatory states such as Dressler’s syn-drome, which is thought to result from an immunecomplex deposition and a subsequent inflammatorycascade post–myocardial infarction (7,8).After pericardiocentesis, our patient developed TTCas evident by TTE, ECG findings, and cTnI elevation.TTC is a stress-induced cardiomyopathy characterizedby transient apical ballooning with regional wall mo-tion abnormalities that occur in association withidentifiable emotional or physical stressors includinginfections (9). The Mayo Clinic proposed the followingdiagnostic criteria for diagnosis of TTC: transientsegmental left ventricular systolic dysfunction,absence of obstructive coronary artery disease, newECG abnormalities or modest cardiac troponin eleva-tion, and absence of pheochromocytoma or myocar-ditis (9). Our patient met these diagnostic criteriaclinically and echocardiogram was consistent withapical ballooning. Cardiac magnetic resonance wouldhave definitively ruled out the presence of myocar-ditis. However, it was not performed, as the patient’scondition continued to improve, and we sought tofurther avoid nonessential medical testing to mini-mize spread of the disease. Acute coronary syndromewas unlikely, as coronary angiography from 2 yearsprior showed no significant coronary arterydisease, and the patient demonstrated no symptomsof acute coronary syndrome. Although TTC hasbeen widely reported in the setting of severebacterial infections, cases of TTC attributed to viralinfections such as influenza are rare (10). In our case,troponin elevation and apical hypokinesis occurredonly after intubation and pericardiocentesis; there-fore, stress from these procedures is also a possibleetiology.FOLLOW-UPOur patient received hydroxychloroquine and low-dose glucocorticoids as per our institutional treat-ment protocol; however, it is important to notethat currently there are no proven data for efficacyof this regimen for COVID-19. We also treated ourpatient with colchicine, given the elevated in-flammatory makers. The patient was continued onguideline-directed medical therapy for nonischemiccardiomyopathy including beta-blockers, angio-tensin receptor blockers, and spironolactone.Repeat TTE prior to discharge demonstrated stableejection fraction and resolution of pericardialeffusion.CONCLUSIONSWe report a rare presentation of COVID-19infection complicated by a large symptomatic hem-orrhagic pericardial effusion and development ofTTC.ADDRESS FOR CORRESPONDENCE: Dr. MohammedF. Dabbagh, Heart and Vascular Institute, Henry FordHospital, 2799 West Grand Boulevard, K14, Detroit,Michigan 48202. E-mail: mdabbag1@hfhs.org.Twitter: @FerrasDabbagh1.J A C C : C A S E R E P O R T S , V O L . 2 , N O . 9 , 2 0 2 0 Dabbagh et al.J U L Y 1 5 , 2 0 2 0 : 1 3 2 6 – 3 0 Cardiac Tamponade Secondary to COVID-191329RE F E RENCE S1. WorldHealthOrganization.Naming thecoronavirusdisease (COVID-19) and the virus that causes it.Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. Accessed March 31, 2020.2. Guan WJ, Ni ZY, Hu Y, et al. Clinical charac-teristics of coronavirus disease 2019 in China.N Engl J Med 2020;382:1708–20.3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiacinvolvement in a patient with coronavirus disease2019 (COVID-19). JAMA Cardiol 2020 Mar 27[E-pub ahead of print].4. Salehi S, Abedi A, Balakrishnan S,Gholamrezanezhad A. Coronavirus disease 2019(COVID-19): a systematic reviewof imagingfindings in919 patients. AJR Am J Roentgenol 2020;215:87–93.5. Adler Y, Charron P, Imazio M, et al. 2015 ESCGuidelines for the diagnosis and management ofpericardial diseases: the Task Force for the Diag-nosis and Management of Pericardial Diseases ofthe European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:2921–64.6. Hamasaki A, Uchida T, Yamashita A, et al.Cardiac tamponade caused by acute coxsack-ievirus infection related pericarditis compli-cated by aortic stenosis in a hemodialysispatient: a case report. Surg Case Rep 2018;4:141.7. Hertzeanu H, Almog C, Algom M. Cardiac tam-ponade in Dressler’s syndrome. Case report. Car-diology 1983;70:31–6.8. Paelinck B, Dendale PA. Images in clinicalmedicine. Cardiac tamponade in Dressler’s syn-drome. N Engl J Med 2003;348:e8.9. Scantlebury DC, Prasad A. Diagnosis of takot-subo cardiomyopathy. Circ J 2014;78:2129–39.10. Cappelletti S, Ciallella C, Aromatario M, et al.Takotsubo cardiomyopathy and sepsis. Angiology2017;68:288–303.KEY WORDS COVID-19, pericardialeffusion, takotsubo cardiomyopathy,tamponadeAPPENDIX For supplemental videos,please see the online version of this paper.Dabbagh et al. J A C C : C A S E R E P O R T S , V O L . 2 , N O . 9 , 2 0 2 0Cardiac Tamponade Secondary to COVID-19 J U L Y 1 5 , 2 0 2 0 : 1 3 2 6 – 3 01330

Cardiac Tamponade Secondary to COVID-19

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Cardiac Tamponade Secondary to COVID-19

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