Case Presentation:
A 17-year-old male with no significant comorbidities presented to the emergency department with seven days of fever, abdominal pain, diarrhea, emesis, and neck pain. There was no reported cough, dyspnea, chest pain, palpitations or syncope. On presentation, he was febrile to 39.5°C, tachycardic with a heart rate of 150 bpm, and hypotensive with blood pressure 79/66 mmHg. His oxygen saturation was greater than 96% in room air and he was in no distress. Heart and lung examinations were normal. He had diffuse abdominal tenderness without hepatomegaly.
Blood tests demonstrated elevated levels of markers of myocardial damage and inflammation, including serum troponin, N-terminal pro-brain natriuretic peptide (NT-proBNP), C-reactive protein, D-Dimer, and Interleukin-6. Other routine blood tests were performed (Table 1). 2019 Novel Coronavirus SARS-COV-2 was detected by nasopharyngeal swab polymerase chain reaction assay. Pertinent miscellaneous tests including urine Legionella antigen and gastrointestinal adenovirus, Ebstein-Barr virus, human herpesvirus-6, enterovirus, and cytomegalovirus yielded no positive results. 12-lead electrocardiogram showed normal sinus rhythm with T-wave inversions in the inferior leads (Figure 1). Cardiac point of care ultrasound (CPOCUS) showed left ventricular (LV) dysfunction. Chest radiograph revealed a normal cardio-thymic silhouette and no infiltrates or focal consolidations.
Three normal saline boluses were administered with improvement in tachycardia and hypotension. Broad spectrum antibiotics (piperacillin and tazobactam) were administered for presumed sepsis. The patient was transferred to the pediatric intensive care unit (PICU) for management of suspected hyperinflammatory syndrome related to cardiac dysfunction and shock.
Upon admission to the PICU, another CPOCUS study was performed using a Philips Lumify transducer which showed mildly decreased LV systolic function (LVEF of 43% by 5/6 area length method) and regional wall motion abnormalities predominantly involving the mid-ventricular level inferior wall as well as the inferior septum (Video 1). Cardiac magnetic resonance imaging (CMRI) was performed to further evaluate myocardial function and characterization; this confirmed the diminished LVEF of 40% and regional hypokinesia, but also showed mild systolic dysfunction of the right ventricle (RVEF of 39%). Additionally, CMRI showed a small area of mid wall late gadolinium enhancement (LGE) involving the mid-ventricular level inferior septum at the inferior LV-RV junction (Figure 2a). This corresponded with the area of increased myocardial signal on T2-weighted fast spin echo images (Figure 2b), suggestive of myocardial edema. Overall findings were consistent with global cardiac dysfunction but also confirmed focal inflammation of the myocardium. Hydroxychloroquine was initiated empirically for COVID-19 once the QTc was confirmed to be normal but was discontinued on day 3 given QTc prolongation. He remained hemodynamically stable during his hospitalization without the use of vasopressors. His electrocardiographic abnormalities resolved, and troponin levels that peaked at 6.170 ng/mL, were near-normal by hospital day 5 (Table 1). He was discharged home on day 5 of hospitalization with outpatient follow-up by cardiology.