Introduction
On December 31, 2019, several cases of pneumonia-like illness were attributed to a seafood wholesale market in the Wuhan province of China (1). On January 7, 2020, the public health officials in China confirmed that these cases were caused by the novel severe acute respiratory distress syndrome coronavirus 2, SARS-CoV-2, also referred to as COVID-19 (2). Recent epidemiologic data has indicated coronavirus to be highly contagious with high risk of person-to-person transmission (3,4). On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. As of April 9, 2020, there have been a total of 1,587,209 cases and 95,455 deaths reported in at least 209 countries (5). As of April 9, 2020, 456,828 of these cases and 16,548 of these deaths have been reported in the United States (5).
Age, male sex, and comorbidity seem to be risk factors for poor outcomes in COVID-19 patients. Despite a low overall case fatality rate of 2.3%, mortality rates among COVID-19 cases are higher among elderly (14.8% in patients over 80 years) and among patients with cardiovascular disease, hypertension, and diabetes (10.5%, 6.0%, and 7.3%, respectively) (6). Earlier study suggested the most common symptoms associated with COVID-19 are fever (88%) and dry cough (67.7%). Less common symptoms include rhinorrhea (4.8%) and gastrointestinal symptoms such as diarrhea (4-14%) and nausea (5%)(7). 14% of patients experienced severe symptoms such as shortness of breath, hypoxia, and respiratory distress. 5% of patients were critical requiring mechanical ventilation in an intensive care unit with clinical presentation of respiratory failure, septic shock, and/or multiorgan failure (8).
Radiological investigations including chest x-ray and CT scan of chest are characterized by findings of bilateral ground glass interstitial infiltrates indicative of atypical pneumonia. Laboratory workup often shows leukopenia and thrombocytopenia. There can be associated transaminitis as well as elevated ESR, ferritin, LDH, and d-dimer. Complications include acute respiratory distress syndrome (ARDS), acute cardiac injury, and secondary infections (9).
With the increasing number of confirmed cases and the accumulating clinical data, the cardiac manifestations induced by COVID-19 have generated great concern. Recent study of 138 patients hospitalized with COVID-19 infection showed 16.7% and 7.2% patients later developing arrhythmia and acute cardiac injury, respectively (10). In a separate study 12.5% of patients with COVID-19 were diagnosed with acute myocardial infarction, manifested with elevated cardiac enzymes (9). COVID-19 was also associated with cardiac arrest, acute-onset heart failure, and myocarditis. COVID-19 has not been reported as the cause of abnormalities of cardiac conduction system. We present a case report that describes presence of high-grade atrioventricular (AV block) requiring pacemaker support in a patient affected by COVID-19.