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.